Resection Arthroplasty for Resistant Ulcers Underlying the Hallux in Insensate Diabetics

BACKGROUND

Foot ulcers carry considerable morbidity in patients with peripheral neuropathy and frequently lead to foot amputation. The purpose of this study was to present our experience treating recalcitrant ulcers underlying the hallux interphalangeal joint in patients with diabetes mellitus (DM)-related neuropathy with a first metatarsophalangeal (MTPJ1) resection arthroplasty.

METHODS

We retrospectively reviewed the computerized medical files of patients with diabetic neuropathy treated with a MTPJ1 resection arthroplasty. We performed 28 arthroplasties on 20 patients with a mean age of 59 years. The patients had a diagnosis of DM for a mean of 10.7 years. Of the ulcers, 26 were grade 1A ulcers, and 2 were grade 2A ulcers (University of Texas score); the ulcer's mean age was 5.4 months. The mean dorsiflexion of the hallux before surgery was 46 degrees.

RESULTS

The primary ulcer recovered in a mean of 3.1 weeks. Major complications (wound dehiscence and infection) occurred in 6 of 28 operations. Patients returned to normal activity 4 weeks after all procedures except in the 6 patients with dehiscence. In a subgroup of patients with follow-up longer than a year, the ulcer recurred after 4 of 18 arthroplasties (22%) between 3 and 12 months due to postoperative hallux rigidus. In the remaining 14 of 18 arthroplasties (78%), there was no recurrence during a mean follow-up of 26 months.

CONCLUSION

MTPJ1 resection arthroplasty may be considered in a patient with resistant plantar hallux ulcerations, even in the absence of hallux rigidus. As with all operations on neuropathic feet in patients with DM, the surgeon and the patient should be aware that there is a significant likelihood of complications, but most are treatable.

LEVEL OF EVIDENCE

Level IV, case series.

Hard to heal pressure ulcers (stage III-IV): efficacy of injected activated macrophage suspension (AMS) as compared with standard of care (SOC) treatment controlled trial

The objective of this study was to compare local injections of AMS with SOC treatments for stage III and IV pressure ulcers in elderly patients. It was designed as historically prospective 2-arms non-parallel open controlled trial, and conducted in a department of geriatric medicine and rehabilitation of a university affiliated tertiary hospital. We studied 100 consecutive elderly patients with a total of 216 stage III or IV pressure ulcers, 66 patients were assigned to the AMS group and had their wounds injected, while 38 patients were assigned to the SOC group. Primary outcome was rate of complete wound closure. Time to complete wound closure and 1-year mortality served as secondary outcomes. Statistical analyses were performed at both patient and wound levels. Percentage of completely closed wounds (wound level and patient level) were significantly better (p<0.001/p<0.001, respectively) in all patients in favor of AMS, as well as in the subset of diabetic patients (p<0.001/p<0.001). Similarly, AMS proved significantly better for the subset of those with leg ulcers and with baseline wounds ≤15 cm(2), compared with SOC. There were no statistically significant differences with regard to time to complete closure or 1-year mortality rates in the two groups. It is concluded that there is a significant difference in favor of stage III and IV wound closure rates by AMS, as compared with SOC treatments.

A comparison between CO2laser surgery with and without lateral fold vaporization for ingrowing toenails

BACKGROUND

An ingrowing toenail is an excessive lateral nail growth into the nail fold. It acts as a foreign body and exerts a local pressure sore-like effect, which may result in inflammation and granulation. Several treatment modalities exist, including chemical ablation and different surgical procedures. Here we describe and compare a simple and effective method of partial matricectomy using the CO2 laser (group A) versus a similar method with the addition of lateral nail fold vaporization (group B).

OBJECTIVE

Outcome evaluation of a modified laser treatment modality for ingrowing toenails and determination of the role of lateral fold vaporization in reducing the recurrence of symptoms.

METHODS

Forty patients (mean age 32.45 years) were treated with CO2 laser ablation of toenails between 1999 and 2005 by four physicians. One physician implemented a method that includes lateral nail fold vaporization and resection of the nail segment with its nail bed from 1999 to 2005. Three physicians implemented a similar technique but without lateral fold vaporization between 1999 and 2003, and added lateral fold vaporization to the performed procedure starting in 2004.

RESULTS

The recurrence rate was 37.5% in group A and 6.2% in group B. The overall average disease-free follow-up period was 42.2 months.

CONCLUSION

The use of CO2 laser in the treatment of ingrowing toenails offers an effective modality. We demonstrate the importance of lateral fold vaporization with the CO2 laser both in improving efficacy and in decreasing recurrence rates over a long follow-up period.

Myiasis with Lund's fly (Cordylobia rodhaini) in travelers

Myiasis is an infestation of human tissue by the larvae of certain flies. There are many forms of myiasis, including localized furuncular myiasis, creeping dermal myiasis and wound and body cavity myiasis.1 Cordylobia anthropophaga (the Tumbu fly) and Dermatobia hominis (the human botfly) are the most common causes of myiasis in Africa and tropical America respectively. The genus Cordylobia also contains two less common species, C. ruandae and C. rodhaini. The usual hosts of C. rodhaini are various mammals (particularly rodents), and and humans are accidentally infested. Figure 1 shows the life cycle of C. rodhaini, which occurs over 55 to -67 days.3 The female fly deposits her eggs on dry sand polluted with the excrement of animals or on human clothing. In about 3 days, the larva is activated by the warm body of the host, hatches and invades the skin. As the larva matures, it induces a furuncular swelling. In 12 to -15 days, the larva reaches a length of about 23 mm, exits the skin and falls to the ground to pupate. The adult fly emerges in 23 to -26 days, and the life cycle resumes. In humans, the skin lesion starts as a red papule that gradually enlarges and develops into a furuncle. In the center of the lesion an opening forms, through which the larva breaths and discharges its serosanguinous feces. The lesion is associated with increasing pain until the larva exits the skin. The disease is usually uncomplicated and self-limiting.

[Silicone breast implants with silicone gel and autoimmune disease--are they related?]

Silicone breast implants are used for breast reconstruction and breast augmentation. In the late 80's anecdotal literature describing a possible connection between silicone gel filled breast implants and autoimmune disease accumulated. Emerging concern about the safety of silicone gel implants had led the FDA to restrict their use. The continued use of the implants in postmastectomy reconstruction was allowed, as was their use in a small number of breast augmentation patients who were willing to enroll in long-term studies. In recent years, large meta-analyses established the fact that there is no association between silicone gel breast implants and autoimmune disease. We review the current literature, emphasizing the most important epidemiologic studies.

Dermatobia hominis myiasis among travelers returning from South America

Dermatobia hominis is the most common cause of myiasis in Central and South America, affecting mammals and humans, causing nonhealing furuncle-like lesions. During the years 1994 to 1999, 14 Israeli travelers returning from South America were diagnosed with D hominis myiasis. The approach consists of correct diagnosis and a proper removal of the larvae, after which the patients heal with no complications.

Positive changes in sun-related behavior in Israel (1994-1998)

BACKGROUND

Current preventive measures against skin cancer focus on individual sun protection and early detection. Solar radiation in Israel is powerful, and about one-half of its population is fair skinned. We investigated whether public awareness efforts yielded changes in sun-related behaviors in Israel from 1994 to 1998.

METHODS

The Department of Health Promotion in the Ministry of Health in Israel has been conducting an ongoing research on health knowledge, attitude, and practice, including six closed questions about sun-related behaviors in a general questionnaire. Independent samples of about 3,000 people representing the adult Jewish population (18 years old and above) were surveyed in 1994, 1996, and 1998. Response rates in 1994 and 1996 were about 85 and 80% in 1998.

RESULTS

The number of people reporting sun protection behaviors increased from 34% in 1994 to 41% in 1996 and to 46% in 1998. Periodic medical skin examination increased from 9% of the responders in 1994, to 13% in 1996 and to 16% in 1998. The number of people reporting having fair skin increased from 28% in 1994 to 41% in 1996 and to 43% in 1998.

CONCLUSIONS

There were positive changes in sun-related awareness and behaviors in Israel between 1994 and 1998. These findings support the conclusion that positive gains were associated with the health promotion efforts conducted by the Israel Cancer Society, Ministry of Health, and other Israeli organizations throughout these years.

Treatment of rhinophyma with Er:YAG laser

BACKGROUND AND OBJECTIVE

Rhinophyma is a benign, disfiguring disorder of the nose which presents the end stage of acne rosacea, and can also occasionally result in nasal airway obstruction. We describe the first series of patients treated with Erbium laser.

STUDY DESIGN/MATERIALS AND METHODS

Severe-to-moderate rhinophyma in six patients were treated at our institution between 1995 and 1996, using the Erbium:YAG (Erb:YAG) laser.

RESULTS

All patients achieved marked cosmetic improvement, with no complications. Post-operative healing time was seven to fourteen days-significantly shorter than similar other modalities.

CONCLUSIONS

The Erbium laser provides very accurate tissue ablation and allows the sculpturing of the hypertrophied areas, offering good cosmetic results, with a very short healing period as shown in our study.

Total lower lip reconstruction with innervated muscle-bearing flaps: a modification of the Webster flap

BACKGROUND

Mohs surgery and other surgical techniques are used for the removal of squamous cell carcinoma of the lower lip and may leave a large defect in the vermilion and underlying tissue. When nearly the entire lower lip is excised, reconstruction of this defect is a challenge. Repair requires the matching of vermilion color, maintenance of oral sphincter function and mouth opening size, and retention of sensation. Several techniques have been suggested. We present a modification of the Webster flap for total lower lip reconstruction using innervated muscle-bearing flaps.

OBJECTIVE

To present a surgical technique for the reconstruction of total lower lip defects after excision of squamous cell carcinoma.

METHODS

Innervated muscle-bearing flaps are used and demonstrated in one case. The surgical technique is discussed in detail.

RESULTS

The reconstructive results were excellent. There were no postoperative complications.

CONCLUSION

The use of innervated muscle-bearing flaps is a useful and effective option for the reconstruction of total lower lip defects.

Breast augmentation with fresh-frozen homologous fat grafts

The purpose of this report is to present a patient who underwent breast augmentation with fresh-frozen fat homografts in Russia 10 years ago, despite the publication of major complications following this procedure.

The versatility of the nasolabial flap enhanced by the delay procedure

BACKGROUND

The nasolabial flap is a versatile and effective option for the closure of nasal defects of the cheek and nasal sidewall following Mohs surgery. However, both extirpation of a tumor in the region of the base of the flap or previous use of the flap often destroy the proximal axial blood supply to the flap, excluding its immediate utilization. We describe a different use of the nasolabial flap and a technique for preserving its capacity in the case of reutilization

OBJECTIVE

To describe the versatility of the nasolabial flap and a delay procedure that enables its exploitation despite prior disruption of the proximal blood supply.

METHODS

Three different uses of the same nasolabial flap are demonstrated in one patient. The surgical techniques are discussed in detail.

RESULTS

The reconstructive results were excellent. There were no postoperative complications.

CONCLUSION

The nasolabial flap is a versatile and effective option for the closure of nasal defects of the cheek and nasal sidewall. When the nasolabial flap has been used before, or its blood supply compromised, the delay procedure can reestablish its applicability.

Photodynamic therapy of cutaneous lymphoma using 5-aminolevulinic acid topical application

BACKGROUND

Photodynamic therapy (PDT) with topical application of 5-aminolevulinic acid (ALA) is a new and effective modality for treatment of superficial basal and squamous cell carcinomas.

OBJECTIVE

We present the kinetics of ALA-induced protoporphyrin IX (PP) accumulation and the results of ALA PDT treatment on two patients with different stages (stage I and stage III) of mycosis fungoides (MF)-type cutaneous T-cell lymphoma (CTCL).

METHODS

ALA-Decoderm cream was applied to the lesions for 16 hours. Spectrofluorescence measurements of PP accumulation were carried out before, during, and 1 hour after photoirradiation (580-720 nm) using the VersaLight system.

RESULTS

Different patterns of PP fluorescence kinetics were observed in patients with early and advanced stages of the disease. During photoirradiation the intensity of fluorescence decreased depending on the lesion thickness. One hour after the photoirradiation procedure no PP fluorescence was observed in the stage I MF lesion, while in the thick stage III MF lesions, PP fluorescence reappeared; after an additional 10-15 minutes of irradiation PP fluorescence disappeared. Complete response with excellent cosmetic results was observed in the stage I lesion after a single irradiation with a light dose of 170 J/cm2; in five stage III lesions, complete response was achieved after fractionated irradiation with a total light dose of 380 J/cm2 (follow-up at 27 and 24 months, respectively).

CONCLUSION

The results showed a high response of both stage I and stage III MF lesions to ALA PDT. This modality appears to be very effective and can be used successfully for MF treatment.

Physiological and neuropsychological effects of theophylline in chronic obstructive pulmonary disease

The effect of oral theophylline on clinical course, exercise, neuropsychological performance and bronchial reactivity was studied in chronic airflow obstruction. Twelve patients with chronic obstructive pulmonary disease (COPD) [mean age 62.4 +/- 1.6 years (SE), and forced expiratory volume in 1 sec of 1.15 +/- 0.1 l] were randomized to 4 weeks treatment with oral theophylline followed by 4 weeks of placebo, in a double-blind fashion. During each period, patients underwent clinical evaluation, incremental exercise, a battery of neuropsychological tests measuring a wide range of cognitive functions, and an inhaled methacholine provocation. On the active drug (levels 9.5 +/- 1 mg/l), vital capacity and maximal breathing capacity were 16 +/- 7% and 20 +/- 7% respectively, higher relative to placebo (P < 0.04). Exercise capacity, as reflected by peak O2 uptake and the anaerobic threshold, improved 14 +/- 5% and 18 +/- 5% (P < 0.04). In contrast, bronchial responsiveness to inhaled methacholine and the mean scores on the neuropsychological tests were not significantly altered by the drug. Clinical symptoms were unaltered, but mild side effects were more common on theophylline. We concluded that in moderate to severe COPD, theophylline treatment, at the low range of the therapeutic dose, improves lung function and exercise capacity. This improvement is achieved with no detectable alteration of bronchial reactivity to methacholine and with no deleterious effect on cognitive functions.

Tumor prostaglandin levels correlate with edema around supratentorial meningiomas

The pathophysiological mechanisms to explain peritumoral edema have not been clarified. Multiple aspects of brain edema secondary to supratentorial meningiomas were prospectively investigated in a group of 29 patients who underwent surgery consecutively. Sixty-nine tumor samples were analyzed for prostanoid levels. Levels of 6-keto-PGF1 alpha, the stable metabolite of prostacycline, were found to correlate well with the extent of edema (r = 0.51, P < 0.01). The ratio, 6-keto-PGF1 alpha x PGE2/TXB2, was found to have the best correlation with edema index (extension/tumor volume) (r = 0.69, P < 0.005). A case of a hemangiopericytic meningioma with the largest edema extent within the study group also exhibited the highest level of 6-keto-PGF1 alpha (2420 pg/mg protein). Steroid treatment (dosage, duration of therapy, and their product) did not correlate with prostaglandin levels. These findings may explain the inconsistent clinical effects of steroids on meningioma-induced edema. Possible explanations for this phenomenon are discussed. Otherwise, histology, pathological features of tumor aggressiveness, or mechanical parameters, such as its volume, location, and insertion site, did not correlate well with edema parameters or with prostaglandin levels. Similarly, tumor water content, imaging parameters in computed tomography and magnetic resonance, and operative findings (including dissection plane, vascularity, and tumor firmness) did not correlate well with edema parameters. Although a direct cause-effect relationship between prostaglandins and peritumoral edema is not conclusively established, the circumstantial evidence of the ability of prostaglandins to induce vasogenic brain edema and the robust association with peritumoral edema is persuasive.(ABSTRACT TRUNCATED AT 250 WORDS)