Epidermal kinetic alterations required to generate the psoriatic phenotype: a reappraisal

OBJECTIVES

Although there have been major advances in understanding immunopathogenesis of psoriasis, the basic processes causing psoriatic morphology remain to be identified.

MATERIALS AND METHODS

Our group has designed a systematic review of studies (1962-2009) on keratinocyte kinetics in psoriasis. We obtained data from MEDLINE, PubMed, Current Contents, reference lists and specialist textbooks. A general equation for evolution of the differentiated epidermis has been analysed. Necessary conditions for observed qualitative change in homeostasis between normal skin and established psoriatic lesions were determined.

RESULTS AND DISCUSSION

Increase in the number of cell divisions (or imbalance in symmetric division rates of committed progenitor cells) and/or decrease in physiological apoptosis in the germinative compartment, together with feedback loops that limit thickening of the skin, are required to generate psoriatic morphology, that is, to increase the absolute size but decrease relative size of the differentiated cell compartment with respect to the germinative compartment.

Curettage treatment for molluscum contagiosum: a follow-up survey study

BACKGROUND

Although curettage is commonly used to treat molluscum contagiosum, prospective studies on its effectiveness are lacking.

OBJECTIVES

To evaluate prospectively the efficacy of curettage in the treatment of molluscum contagiosum and to identify the risk factors associated with treatment failure.

METHODS

A systematic 2-month follow-up survey study was carried out on 73 patients treated by curettage for molluscum contagiosum.

RESULTS

Treatment of molluscum contagiosum by curettage was associated with a high risk of treatment failure at week 4 (42/64, 66%) and at week 8 (25/55, 45%). Risk factors for treatment failure at week 4 and 8 were the number of lesions at day 0 (P < 0.001), the number of involved anatomical sites (P < 0.001) and concomitant atopic dermatitis (P = 0.038 and P < 0.001, at weeks 4 and 8, respectively).

CONCLUSIONS

The main risk factor for treatment failure is lesion number, underlining the importance of the early detection of the lesions or, alternatively, emphasizing the need for therapeutic options other than curettage in patients with numerous lesions.

Origin of threshold behaviour in psoriatic skin

The mechanisms that lead to the psoriatic morphology are not fully elucidated. Several lines of evidence suggest that the positive feedback between keratinocytes and immunocytes plays a key role in the development of the lesions. On the other hand, little information is available on the negative regulatory controls that maintain a new homoeostasis level in psoriatic skin. We suggest here that the interplay of these two contrary feedbacks is likely to entail a hysteresis effect and that psoriasis is likely to be interpreted as a critical phenomenon characterized by a catastrophic shift of the skin from a normal to a hyperplastic state.

Efficacy of tetracyclines in the treatment of acne vulgaris: a review

BACKGROUND

Oral tetracyclines are routinely used for the management of inflammatory acne. However, there is a lack of evidence-based data on their relative effectiveness and appropriate dosages.

OBJECTIVES

To assess the relative effectiveness and the optimal dosage of tetracyclines for the treatment of inflammatory acne.

METHODS

We designed a systematic review of the clinical trials (1962-2006) investigating oral tetracyclines for the treatment of inflammatory acne. We obtained data from MEDLINE, PubMed, Current Contents, reference lists and specialist textbooks.

RESULTS

There was substantial heterogeneity in the design of the trials. We identified only seven randomized trials which were set up to compare the efficacy of tetracyclines in reducing acne lesion counts. These showed no evidence of superiority of one tetracycline over another. Overall, there was also no significant difference between the available tetracyclines in terms of improvement in inflammatory (32 trials, P=0.898) and noninflammatory (23 trials, P=0.429) lesions. In the range of investigated dosages, the antibiotic dosage had no impact on efficacy in inflammatory (P=0.609) and noninflammatory (P=0.654) lesions. There was no decrease in efficacy during the study period.

CONCLUSIONS

There is insufficient evidence to support one tetracycline rather than another in terms of efficacy. In the range of investigated dosages, the antibiotic dosage seems to have no impact on efficacy. Despite increased resistance to antibiotics, oral tetracycline formulations displayed no change in efficacy during the study period. Further studies are, however, required to determine if the anti-inflammatory properties of tetracyclines are sufficient in managing acne.

Treatment of axillary hyperhidrosis with botulinum toxin type A reconstituted in lidocaine or in normal saline: a randomized, side-by-side, double-blind study

BACKGROUND

Botulinum toxin type A represents a safe and effective treatment for primary axillary hyperhidrosis. One of the most troublesome disadvantages associated with this therapy is pain at the injection sites. Reconstitution of botulinum toxin A in a solution of lidocaine could be an easy alternative procedure to reduce the discomfort associated with those injections. However, the current recommendations are that botulinum toxin A should be reconstituted in normal saline.

OBJECTIVES

To compare the efficacy and tolerance profile of saline-diluted botulinum toxin A and lidocaine-diluted botulinum toxin A in patients with axillary hyperhidrosis.

METHODS

In a double-blind, side-by-side, controlled, randomized clinical trial, 29 patients were injected with 100 mouse units of botulinum toxin A (Botox); Allergan Pharmaceuticals Ireland, Westport, Ireland) reconstituted in lidocaine into one axilla and with the same dosage of the toxin, reconstituted in an equal volume of saline, into the other axilla. The patients were followed up for 8 months. Quantification of sweat production was performed by iodine-starch tests and by the patients' own rating of sweating. The intensity of pain associated with the botulinum toxin intracutaneous injections was self-assessed by the patients and was evaluated using a 100-mm visual analogue scale.

RESULTS

Botulinum toxin A diluted in normal saline and botulinum toxin A diluted in lidocaine were similarly effective in terms of control of onset of sweat production, duration of effect and subjective percentage of mean decrease in sweating. Both treatments were well tolerated, and there were no lasting or severe adverse effects. However, the mean +/- SD pain score during the procedure was significantly lower in the axillae treated with lidocaine-reconstituted botulinum toxin than in the axillae treated with saline-reconstituted botulinum toxin (29.3 +/- 20.1 vs. 47.5 +/- 24.0; P = 0.0027).

CONCLUSIONS

Short- and long-term results show the equal effectiveness of botulinum toxin A reconstituted in saline or in lidocaine. However, because injections of botulinum toxin A reconstituted in lidocaine are associated with significantly reduced pain, lidocaine-reconstituted botulinum toxin A may be preferable for treating axillary hyperhidrosis.

Treatment of acne with topical antibiotics: lessons from clinical studies

BACKGROUND

Over the past 20 years, major concerns have been repeatedly expressed over antibiotic-resistant acne in Europe and in the U.S.A. However, the clinical significance of these resistance patterns is poorly defined so that topical antibiotics remain one of the cornerstones of acne management.

OBJECTIVES

To determine whether we are facing decreased efficacy of topical formulations of erythromycin and clindamycin in clinical trials of therapeutic interventions for acne.

METHODS

To review systematically the results of the clinical trials investigating topical formulations of erythromycin and clindamycin for the treatment of inflammatory acne and to establish whether or not there is a decrease in the efficacy of these topical antibiotic formulations since their widespread introduction in the mid 1970s.

RESULTS

Of the 50 eligible controlled trials identified using a systematic electronic database search strategy, 45 (90%) incorporated a lesion count, making comparison across trials possible. Analysis of clinical studies investigating the effect of topical erythromycin in acne patients indicates a significant decrease in the effect of this antibiotic on inflammatory and noninflammatory lesion count over time (r = -2.140, P = 0.001 and r = -2.032, P = 0.001, respectively). Efficacy of topical clindamycin remained stable during the study period.

CONCLUSIONS

There is a gradual decrease in the efficacy of topical erythromycin in clinical trials of therapeutic intervention for acne, which is probably related to the development of antibiotic-resistant propionibacteria.

The importance of serum creatine phosphokinase level in the early diagnosis and microbiological evaluation of necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis (NF) due to group A beta-haemolytic streptococci (GAS) is a rare but still life-threatening soft-tissue infection characterized by rapidly spreading necrosis of the muscle fascia and of the surrounding tissues. NF other than that due to GAS involves the participation of one or more anaerobes and/or of non-group A streptococci, Staphylococcus aureus, enteric organisms, and may be associated with a better outcome. Early diagnosis and treatment, consisting of surgical debridement along with appropriate antibiotic therapy, are required to reduce morbidity and mortality rates.

OBJECTIVES

The aim of the study was to analyse the clinical and laboratory findings of patients with GAS NF and with non-GAS NF, and to identify which characteristics could help to diagnose NF in the early stages of infection.

METHODS

We retrospectively analysed the clinical and laboratory findings of 43 cases of GAS and non-GAS NF that occurred in Belgium (n = 32) and at Saga Medical School (Japan) (n = 11) between May 1984 and December 2001.

RESULTS

GAS NF more frequently occurred in previously healthy individuals than NF due to other pathogens (P < 0.05) but was associated with a poorer prognosis. Both for patients with GAS NF and with non-GAS NF, the first clinical manifestations often suggested a diagnosis of erysipelas or cellulitis and rarely evoked the correct diagnosis (12% and 15% of the cases, respectively). However, we found that creatine phosphokinase (CPK) values were far higher in patients with GAS NF than in those with non-GAS NF.

CONCLUSIONS

Our data suggest that GAS may exert particular tropism and/or toxicity for muscle, responsible for early muscle necrosis. This indicates that elevated levels of CPK in a patient with erysipelas or cellulitis-like symptoms should clearly prompt the clinician to exclude the diagnosis of GAS NF.

Group A Beta-Haemolytic Streptococcal Necrotising Fasciitis: Early Diagnosis and Clinical Features

Necrotising fasciitis (NF) due to group A beta-haemolytic streptococci (GAS) is a rare but still life-threatening soft-tissue infection characterised by rapidly spreading inflammation and subsequent necrosis of the muscle fascia and of the surrounding tissues. Previous studies have emphasised that the outcome of patients with NF depends essentially on early diagnosis and treatment, consisting of extensive surgical debridement, along with appropriate antibiotic therapy. However, one of the striking features of the published series of GAS NF is that there was a delay in diagnosis in several cases, which underscores the difficulty of the early diagnosis of the condition. The goal of this article was to review the clinical features and diagnostic tools that could facilitate the early recognition of GAS NF.

Management of drug rash with eosinophilia and systemic symptoms (DRESS syndrome): an update

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a rather distinct severe adverse drug reaction characterised by skin rash, fever, lymph node enlargement and internal organ involvement. Our aim was to review the available data regarding the management of this probably underrecognised subset of drug reaction. So far, the only undisputed way to treat severe hypersensitivity reactions is prompt withdrawal of the offending drug. The use of systemic corticosteroids remains controversial. The benefit of therapies aimed at accelerating the elimination of the causative drug deserves further studies. In the absence of a well-established therapy, primary and secondary prevention have a key role in the management of DRESS syndrome.

[The dermatology department]

The department of dermatology has developed a broad clinical activity with a particular expertise in oncology, allergology, psoriasis and gynecological dermatology. Research has also been developed in these areas.

Human herpesvirus 8 investigations: a role in the clinical management of Kaposi's sarcoma?

Kaposi's sarcoma (KS) is a vascular tumour associated with infection by human herpesvirus 8 (HHV-8). Most of the recent studies on KS have focused on the epidemiology and molecular biology of HHV-8. However, the contribution of virological investigations into HHV-8 to the clinical management of KS has been poorly evaluated so far. From a diagnostic point of view, HHV-8 currently appears as a useful tool for distinguishing KS from its mimics. Seroconversion to antibodies against HHV-8 may predict the development of KS in susceptible individuals, and reduction of HHV-8 viraemia is associated with therapies effective against KS. Further prospective studies are still required to determine the role of serological or genotypic investigations into HHV-8 in the prevention of KS and in KS response to therapy.

Enhancement of classic Kaposi's sarcoma growth after intralesional injections of desferrioxamine

We have previously shown that iron may be involved in the pathogenesis of Kaposi's sarcoma (KS) and that the iron chelator desferrioxamine (DFO) inhibits the growth and induces the apoptosis of KS cells in vitro. We treated an 85-year-old man with classic KS with 5 weekly intralesional injections of DFO and observed the opposite effect in vivo. The DFO-treated lesion was characterised by the development of numerous KS papules within the drug diffusion area, whereas no change was noted in untreated or control saline-treated lesions. This suggests that intralesional iron chelators are not indicated in patients with KS.

Treatment of Kaposi's sarcoma with human chorionic gonadotropin

Clinical-grade preparations of human chorionic gonadotropin (hCG) have been shown to be toxic to Kaposi's sarcoma (KS) cells. However, the mechanism of the anti-KS activity achieved with these preparations remains unclear. The results of clinical studies using commercial hCG preparations in human KS are also highly contradictory. The apparent controversy between different studies may be due to the fact that pro- and anti-KS components are present in varying proportions in different hCG preparations. As certain hCG preparations could not only lack the ability to control KS but also contain some contaminant KS growth factor(s), we suggest a cautious use of crude hCG for the treatment of KS.

Stimulation of Kaposi's sarcoma cell growth by urine from women in early pregnancy, the current source for clinical-grade human chorionic gonadotropin preparations

Clinical-grade preparations of human chorionic gonadotropin (hCG) have been shown to be toxic to Kaposi's sarcoma (KS) cells. However, the results of clinical studies using commercial hCG preparations KS remain highly contradictory. More particularly, some hCG preparations could have a paradoxical growth effect on KS. Such discrepant results may be explained by the fact that the anti-KS activity is not associated with hCG itself but with one or more factors that are co-purified with the hormone. We found here that crude urine from first trimester pregnant women, the current source for commercial hCG, had a growth stimulatory effect on KS cells. By contrast, urine from last trimester pregnant women, from non-pregnant young women, from menopausal women and from men exhibited neither a growth stimulatory nor a growth inhibitory effect on KS cells. The amplitude of this pregnancy urine-associated pro-KS activity/hCG unit was higher than that achieved with clinical-grade hCG preparations. Partial co-purification of pregnancy-associated factors during the extraction procedure of commercial hCG from urine may explain the pro-KS activity achieved with some hCG preparations. We, therefore, suggest a cautious use of hCG purified from pregnancy urine for the treatment of KS.

Hyperalgesia, nerve infiltration and nerve growth factor expression in deep adenomyotic nodules, peritoneal and ovarian endometriosis

BACKGROUND

The aim of this study was to investigate a possible role for nerve growth factor (NGF) in the mechanism of pain and hyperalgesia induced by deep adenomyotic nodules and other forms of endometriosis and to clarify the relationship between endometriotic lesions and the surrounding nerves.

METHODS

Endometriotic lesions (deep adenomyotic nodules, peritoneal endometriosis, ovarian endometriosis) and eutopic endometrium were obtained from 51 patients presenting with pain. Patients were allocated to two groups (group 1: patients with a deep adenomyotic nodule (n = 23); group 2: patients with peritoneal and/or ovarian endometriosis but without deep adenomyotic nodule (n = 28). Immunohistochemistry with antibodies against NGF, NGF specific tyrosine-kinase receptor (Trk-A) and S-100 protein was performed. Results were expressed as mean H-scores +/- SD, and correlated with the presence of hyperalgesia.

RESULTS

The percentage of patients presenting hyperalgesia at physical examination was significantly higher in group 1 (96%) than in group 2 (11%) (P < 0.001). NGF expression was significantly stronger in deep adenomyotic nodules (DAN) than in ovarian (OE) and peritoneal endometriosis (PE), both in the proliferative phase in the glands [DAN: 226 +/- 18; OE: 140 +/- 9 (P < 0.001); PE: 110 +/- 7 (P < 0.001)] and in the stroma [(DAN: 204 +/- 21; OE: 125 +/- 15 (P < 0.001); PE: 100 +/- 9 (P < 0.01)]. NGF expression in DAN is also significantly stronger than in OE and PE in the secretory phase in the glands [DAN:181 +/- 32; OE: 85 +/- 3.3 (P < 0.001); PE: 65 +/- 9 (P < 0.001)] and in the stroma [DAN: 173 +/- 28; OE: 85 +/- 3.7 (P < 0.001); PE: 35 +/- 13 (P < 0.001)]. Perineurial and intraneurial invasion by endometriotic lesions were found only in deep adenomyotic nodules and not in the other forms of endometriosis. The specific receptor for NGF (Trk-A) is expressed in all the nerves that were included in the biopsies.

CONCLUSIONS

These results suggest a role of NGF in endometriotic pain and hyperalgesia in deep adenomyotic nodules. The strong expression of the NGF-TrkA pathway in deep adenomyotic nodules could explain why this type of lesion infiltrates in richly innervated anatomical sites.

An immunohistochemical study of abnormal keratinocyte proliferation in molluscum contagiosum

BACKGROUND

Molluscum contagiosum is a common cutaneous tumour that is characterized by usually spontaneous involution and self-limited spreading in immunocompetent individuals.

OBJECTIVE

We aimed to investigate the apoptosis and the expression of cell-cycle proteins in molluscum contagiosum lesions.

METHODS

The terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labelling (TUNEL)-based apoptotic index and the expression of the cell-cycle proteins Ki-67, p53, p21WAF and Bcl-2 were investigated in molluscum contagiosum lesions obtained from the trunk of 20 immunocompetent patients and in normal skin samples from the trunk of six healthy volunteers.

RESULTS

Whereas molluscum contagiosum lesions displayed a TUNEL-based apoptotic index similar to that of normal skin, they exhibited an increased Ki-67 index, which was confined to the basal and first suprabasal layers (P < 0.001). Compared with normal non-sun-exposed skin, molluscum contagiosum lesions also exhibited increased p53 staining in basal cells (P < 0.01), increased p21WAF in suprabasal cells (P < 0.001) and loss of Bcl-2 expression.

CONCLUSIONS

These results indicate that molluscum contagiosum lesions exhibit an increased proliferation rate of keratinocytes, which is likely to be partially counteracted by accumulation of p53.

Treatment of idiopathic palmar hyperhidrosis with botulinum toxin. Report of 23 cases and review of the literature

BACKGROUND

Botulinum toxin represents a novel therapeutic option for idiopathic palmar hyperhidrosis. However, so far there is no consensus on the way to administer botulinum toxin in this indication. Moreover, its use is limited by severe pain during the injections, especially with subepidermal injections close to 'free nerve endings'.

OBJECTIVES

To analyze the effectiveness and tolerability of intracutaneous injections of botulinum toxin after nerve blocks and to review the techniques of injections and the results reported by other groups.

METHODS

Twenty-three adult patients with refractory palmar hyperhidrosis were treated with intracutaneous injections of botulinum toxin after ulnar and median nerve blocks. Patients were followed up on a monthly basis.

RESULTS

In all patients botulinum toxin abolished sweating in the injected areas within 1 week. Anhidrosis lasted for 4-13 months. The intensity of pain was rated as absent (n = 13), mild (n = 8) or moderate (n = 2). Other side effects included hematoma (n = 2) and pain consecutive to nerve block (n = 1).

DISCUSSION

Intracutaneous injections of botulinum toxin after median and ulnar nerve block represent an effective and mildly painful technique to treat palmar hyperhidrosis and may be as safe as subepidermal injections.

Immunologic and virologic response after tetanus toxoid booster among HIV-1- and HIV-2-infected Senegalese individuals

Twelve HIV-1-infected, nine HIV-2-infected patients and eight HIV-negative subjects were given a 40IU booster dose of tetanus toxoid (TT). Blood was collected on days 0, 7 and 30 after immunization. Changes in HIV-1 or HIV-2 RNA load were evaluated by nested PCR. TT-IgG antibody levels were quantified by ELISA. CD4 cell counts as well as activation, memory and maturation markers of T lymphocyte subsets were determined by flow cytometry. The induction of apoptosis was investigated using 7-aminoactinomycin D (AAD) and propidium iodide (PI) staining. Proliferative responses to TT and pokeweed mitogen (PWM) were determined by the level of [(3)H] thymidine incorporation. Seven and 30 days after immunization, there was no detectable increase in HIV-1 or HIV-2 plasma load. There were also no changes in CD4 cell counts, CD69, HLA-DR and memory CD45RO or naive CD45RA antigens. Immunization did not increase the spontaneous apoptosis of peripheral blood mononuclear cells (PBMCs), CD4+ and CD8+ T cells subsets neither in controls nor in HIV-infected patients. Similarly, apoptosis induced in vitro by PWM or by the specific TT recall antigen did not vary during the study period. The proliferative response to PWM and to the TT recall antigen was decreased both in HIV-1- and HIV-2-infected patients compared to HIV-negative controls. Immunization significantly increased the TT-IgG levels in healthy controls and in HIV-infected patients. However, the anti-TT-IgG response, as measured by the fold-increase index between days 0 and 30, was significantly higher in healthy controls than in HIV-1- (P=0.036) and HIV-2-infected patients (P=0.003). In conclusion, we found no deleterious immunologic or virologic effect was detected in healthy HIV-1- and HIV-2-infected individuals after antigenic challenge with a TT booster. However, the response to TT vaccination was lower in HIV-1- and in HIV-2-infected individuals than in healthy HIV-negative controls.

Early- and late-stage Kaposi's sarcoma-derived cells but not activated endothelial cells can invade de-epidermized dermis

Whether Kaposi's sarcoma is a true neoplasm or a reactive endothelial cell outgrowth triggered by inflammatory cytokines remains unclear. In this study, we investigated the differential invasive properties of activated endothelial cells and Kaposi's sarcoma cells in a model of de-epidermized dermis, supplying the cells with matrix barriers similar to those found in vivo. Cells derived from early "patch-stage" and from late "nodular-stage" Kaposi's sarcoma lesions exhibited similar invasive properties, which indicates that cells with an invasive potential are present in the early stages of tumor development. Slow accumulation of the cells into the extracellular matrix, together with a low proliferation index and with expression of anti-apoptotic proteins, suggest that the progression of Kaposi's sarcoma may be related to escape from cell death rather than to increased proliferation. The Kaposi's sarcoma-Y1 cell line, which is tumorigenic in nude mice, also exhibited invasive properties. By contrast to the Kaposi's sarcoma-derived spindle cells, however, which were scattered between the collagen bundles, the Kaposi's sarcoma-Y1 cell population had a higher proliferation index and displayed a multilayer arrangement. Inflammatory cytokines and Kaposi's sarcoma cell supernatant could activate and stimulate the growth of human dermal microvascular endothelial cell, but could not induce their invasion in this model, showing that activated endothelial cells do not fit all the requirements to traverse the various barriers found in the dermal extracellular matrix. These results confer to Kaposi's sarcoma cells a tumor phenotype and suggest that the in vivo dominant endothelial cell population represents a reactive hyperplasia rather than the true tumor process.

Iron induces Bcl-2 expression in human dermal microvascular endothelial cells

Iron is suspected to be involved in the induction and/or progression of various human tumors. The present study was designed to investigate the effects of iron on endothelial cells, keeping in mind that the homeostasis of microvessels plays a critical role in neo-angiogenesis. Applying a model of human dermal microvascular endothelial cell terminal differentiation and death induced by serum deprivation, we found that iron salts (iron chloride and ferric nitrilotriacetate) provided a survival advantage to endothelial cells. Using immunohistochemistry and Western Blot analysis, we found that the extended cellular life span induced by iron was paralleled by an increase of Bcl-2 protein expression. Taken together, these observations suggest that iron may give a survival advantage to endothelial cells and represent a novel mechanism through which iron may contribute to tumorigenesis.

Impact of surgical resection of rectovaginal pouch of douglas endometriotic nodules on pelvic pain and some elements of patients' sex life

STUDY OBJECTIVE

To assess the impact of laparoscopic resection of endometriotic nodules in the rectovaginal pouch of Douglas on women's pain symptoms, analgesic intake, work absenteeism, work difficulties, and some elements of sex life.

DESIGN

Observational study (Canadian Task Force classification II-2).

SETTING

Gynecology department at a university hospital.

PATIENTS

Twenty-six women with rectovaginal pouch of Douglas endometriotic nodules and no evidence of other potential cause of pain at physical examination, laparoscopy, and transvaginal ultrasonography.

INTERVENTION

Laparoscopic resection of endometriotic nodules with the CO2 laser until no residual induration was felt in surrounding tissues.

MEASUREMENTS AND MAIN RESULTS

Significant statistical differences were found between preoperative and postoperative pain scores, percentages of women absent from work, percentages taking analgesics or nonsteroidal antiinflammatory drugs, and percentages having work difficulties due to pain. A significant difference also was found in frequencies of sexual desire and coitus.

CONCLUSION

Endometriotic nodules in the rectovaginal pouch of Douglas may be responsible for major pelvic pain and also for sexual dysfunction (lack of sexual desire, dyspareunia). Laparoscopic resection of the nodules significantly improves these conditions. (J Am Assoc Gynecol Laparosc 8(1):55-60, 2001)