Xanthoma disseminatum in an infant with skeletal and marrow involvement

PURPOSE

Xanthoma disseminatum is a rare non-Langerhans' histiocytosis of older children and adults with characteristic lesions involving the skin, mucous membrane and occasionally internal organs. We describe a case, presenting in infancy, with unique clinical features.

PATIENT AND METHODS

The patient presented at 8 months of age with skin lesions subsequently found to have histologic, immunophenotypic, and ultrastructural characteristics of non-Langerhans' histiocytosis. In addition to extensive skin lesions, the patient also has involvement of the buccal mucosa, lips, eyelids, bones, bone marrow, and possibly liver and spleen.

RESULTS

Clinical and pathological features of the patient are suggestive of xanthoma disseminatum. Treatment with cytotoxic, immunomodulatory, and lipid-lowering agents has been unsuccessful to date.

CONCLUSION

Unique characteristics of this case of xanthoma disseminatum include the patient's young age, lytic bone lesions, and previously undescribed bone marrow involvement.

The use of adjunctive thrombolytic therapy in the management of acute popliteal aneurysm thrombosis

Acute thrombosis of a popliteal aneurysm frequently results in limb loss due to thromboembolic occlusion of the tibioperoneal "outflow" tract. In these patients, the best prognostic indicator of limb salvage is the patency status of the tibioperoneal vessels. When these outflow vessels are occluded at arteriography, intraarterial fibrinolytic therapy may reestablish outflow when none is present preoperatively, thereby allowing the opportunity for dependable distal reconstructive surgery and thus limb salvage.

Infrainguinal endovascular in situ saphenous vein bypass: ongoing results

PURPOSE

With 70 cm "cutter" valvulotomes for valvulotomy and an electronically steerable nitinol catheter to occlude venous tributaries with platinum coils, endovascular in situ saphenous vein (EISV) bypass can be safely performed from within the saphenous vein. To determine whether EISV bypass could reduce hospital length of stay (LOS) and perioperative morbidity without compromising patency, another 53 EISV bypasses for limb salvage were performed.

METHODS

Tributary occlusion was accomplished with only fluoroscopic surveillance with a new, smaller, and more steerable silicone-tipped nitinol catheter.

RESULTS

Two (3.7%) wound complications occurred. The mean hospital LOS after operation was 4.2 days (range 2 to 29 days). All tributaries initially embolized remained occluded, and three "missed" arteriovenous fistulas were identified during follow-up extending to 15 month (mean 8.4 months). Eighty-eight percent (49 of 54) of phase II bypasses remained patent, whereas life-table analysis of all bypasses (phase I and II) was 77% (69/99) at 24 months follow-up (mean 13.6 months). By comparison, 41 infrainguinal saphenous vein in situ bypasses with "classic" open techniques were performed concurrently. The mean postoperative LOS was 11.6 days (range 4 to 42 days), wound complications occurred in 24% (10) of patients, and two "missed" arteriovenous fistulas were identified during follow-up. Eighty-three percent (34 of 41) of bypasses remain patent at 24 months follow-up (mean 16.2 months).

CONCLUSIONS

If EISV bypass long-term patency rates remain similar to classic in situ bypass patency results, the additional benefits of decreased hospital LOS, reduced wound-related complications, shortened recuperation, and therefore increased health care savings gives this endovascular technique strong consideration as the possible future operation for infrainguinal saphenous veins in situ bypass.

Expression and characterization of a fusion protein between the catalytic domain of poly(ADP-ribose) polymerase and the DNA binding domain of the glucocorticoid receptor

A fusion protein comprising the DNA-binding region of the glucocorticoid receptor and the catalytic domain of poly(ADP-ribose) polymerase was constructed. This chimeric protein was expressed both in E. coli and in eukaryotic cells and was recognized by antibodies to both polymerase and the glucocorticoid receptor. Similar to polymerase, the chimera produced bona fide poly (ADP-ribose) polymers covalently bound to protein and was inhibited by 3-aminobenzamide. Like the authentic glucocorticoid receptor, the fusion protein formed a stable complex with DNA containing the glucocorticoid response element. In mammalian cells, the fusion protein significantly and specifically inhibited the ability of the glucocorticoid receptor to stimulate a reporter construct. These results indicate that polymerase activity can be targeted to specific DNA sequences and modulate gene expression.

Sphingosine 1-phosphate, a novel signaling molecule, stimulates DNA binding activity of AP-1 in quiescent Swiss 3T3 fibroblasts

Sphingosine and sphingosine 1-phosphate, metabolites of sphingolipids, stimulate cell proliferation in quiescent Swiss 3T3 fibroblasts and induce transient increases in intracellular free calcium (Zhang, H., Desai, N. N., Olivera, A., Seki, T., Brooker, G., and Spiegel, S. (1991) J. Cell Biol. 114, 155-167). However, little is yet known of the nuclear events that follow the early responses induced by sphingolipid metabolites. Using a gel retardation assay, we found that specific DNA binding activity of activator protein-1 (AP-1) was markedly increased after treatment of quiescent Swiss 3T3 fibroblasts with sphingosine 1-phosphate and sphingosine. The DNA binding specificity of AP-1 was confirmed with competing probes containing consensus sequences of AP-1, AP-2, AP-3, SP-1, and NF1/CTF. The c-fos gene product was detected in the AP-1 complex using anti-c-Fos antibody. The dose response for stimulation of DNA binding activity of AP-1 by sphingosine 1-phosphate correlated closely with its effect on DNA synthesis. Furthermore, an inhibitor of sphingosine kinase, DL-threo-dihydrosphingosine, which inhibits sphingosine-induced DNA synthesis and the formation of sphingosine 1-phosphate, also inhibited sphingosine-stimulated AP-1 DNA binding activity. This result further supports our proposal that sphingosine 1-phosphate mediates the mitogenic effect of sphingosine. Our results indicate that sphingosine 1-phosphate-induced DNA synthesis and cell division may result from activation of AP-1 protein, linking signal transduction by sphingolipid metabolites to gene expression.

Removal of a protruded thoracic disc using microsurgical endoscopy. A new technique

STUDY DESIGN

The first clinical implementation of a microsurgical endoscopic technique for removal of thoracic disc herniation is described.

OBJECTIVE

To decompress the spinal cord with a ventral approach, combining microsurgical and endoscopic techniques, while reducing the "approach-related trauma."

METHODS

A detailed description of the preoperative preparation as well as the surgical technique is given. Advantages and disadvantages of the microsurgical endoscopic technique are discussed and compared with other surgical procedures described in the literature.

RESULTS

A herniated disc at T6-T7 was removed and the spinal cord was decompressed. The patient recovered completely and was discharged at the seventh postoperative day. He returned to work 4 weeks later.

CONCLUSIONS

The microsurgical endoscopic technique allows spinal cord decompression with a substantial reduction in surgical trauma. It may shorten bed confinement and allow early return to active life. Application of this technique in other areas is being studied.

Laparoscopic common bile duct exploration

Laparoscopic cholecystectomy has rapidly gained recognition and acceptance to the point that it is the procedure of choice for laparoscopically skilled surgeons in handling chronic cholecystitis and most cases of acute cholecystitis (1-3; personal communication, J. Mouret). The low morbidity and mortality rates associated with this approach as well as widespread patient acceptance has established this modality as the preferred method for managing this common disease (1,2,4,5). Controversy continues to surround the handling of common bile duct stones, and several options exist (5-8). This report details a method of laparoscopic choledochotomy as an adjuvant to handling this difficult problem.

Prognosis with newly diagnosed mycosis fungoides after total skin electron radiation of 30 or 35 GY

PURPOSE

To determine the prognosis of new patients with T1-4N0-1B0M0 mycosis fungoides treated with total skin electron beam radiation.

METHODS AND MATERIALS

25 consecutive patients received 30 Gy with 3 or 4 MeV electrons in 1977-1980; 121 received 35 Gy with 4 MeV in 1980-1992. Response rates, relapse-free survival, and overall and cause-specific survivals were assessed by explicit criteria. The relationships of T, N, gender, age, and radiation technique to prognosis were investigated by regression statistics.

RESULTS

The average age was 55 years and the male:female ratio was 1:4. Forty-four percent were T1N0 and 34% were T2N0. The overall complete response rate was 82%, and lower T status, more radiation, and female gender were independently and positively associated with response. Median follow-up was 5.2 years. T1 patients who entered remission had a higher relapse-free survival compared to T2 through T4 patients. Thirty-four percent of T1 patients remained relapse-free at 6 years, compared to fewer than 20% of T2-4 patients. For all 146 patients the median overall survival was not reached at 15 years. Only 8 of 29 deaths were related to mycosis fungoides and these were significantly associated with higher T. The 54 T1N0 patients who had 35 Gy had a 10-year mycosis fungoides-specific survival of 100%.

CONCLUSION

Total skin electron beam radiation gives good results with T1N0B0M0 disease. T3-4 disease is less likely to respond, it relapses more quickly, and it implies a poorer survival, but radiation offers palliation. T2 responds like T1, but relapses like T3-4. T2 also implies an intermediate survival. These results have implications for staging, informed consent, optimizing radiation treatment, and clinical trials.

Use of the Greenfield filter in patients with major trauma

Patients with major trauma often cannot be given the benefit of preventive measures such as pneumatic compression boots and low-dose heparin against pulmonary embolism. The Greenfield filter is accepted as a safe and effective method of prophylaxis of this complication. The aim of this study was to evaluate the efficacy of placement of the Greenfield filter in 161 patients with major trauma. Between January 1984 and July 1988, 94 patients with an injury severity score (ISS) of > 16 were treated. This score is predictive of a mortality rate of at least 10% and defines major trauma based on anatomic injury. Some 20% (19 of 94) of these patients developed deep vein thrombosis despite standard prophylactic measures and 8% (eight of 94) suffered pulmonary embolism, two of which were fatal. Pulmonary embolism occurred without antecedent evidence of deep vein thrombosis in another 15% of patients (14 of 94), three of which caused death. From August 1988 until July 1992, of 67 other patients with an ISS > 16, 13% (nine of 67) developed deep vein thrombosis and 1% (one of 67) had a pulmonary embolism; this was not statistically significant (P > 0.25). Of these 67 patients who were considered to be at high risk of pulmonary embolism, because of a contraindication to anticoagulation or physical impediment to sequential compression boots, 29 had prophylactic placement of a Greenfield filter. No pulmonary emboli occurred in these patients. During long-term follow-up (mean 32.8 (range 4-58) months), 84% of the surviving patients (21 of 25) underwent duplex ultrasonography of the inferior vena cava; patency of the vessel was confirmed in all patients.

Thyroid peroxidase in dyshormonogenetic goiters with organification and thyroglobulin defects

Thyroid peroxidase (TPO) iodide and guaiacol oxidation activities were evaluated in eight dyshormonogenetic goiters. Two of these had a defective thyroglobulin; the TPO iodide oxidation (431 and 316 U/g ptn) and iodination (31 and 8.6 nmol I/mg ptn) activities were within the normal ranges. The goiters from two siblings with positive perchlorate iodide discharge tests also had normal TPO iodide oxidation (602 and 299 U/g ptn) and iodination activities (44 and 11 nmol I/mg ptn). No TPO iodide oxidation activity was found in the goiters from the other four patients with positive perchlorate iodide discharge tests, and TPO iodide oxidation inhibitory activities were detected in both their TPO and thyroglobulin preparations. Three of them had some TPO guaiacol oxidation activity and did not inhibit normal guaiacol oxidation. The TPO preparation immunoblot of these three goiters showed a faintly visible band of normal 100 kDa TPO. However, in the other patient no guaiacol oxidation activity was detected, and only two bands of low-molecular-weight TPO (72 and 43 kDa) were found, again showing that iodine organification defects in dyshormonogenetic goiters can be due to either qualitative or quantitative TPO defects. The TPO inhibition diminished when iodide was increased in the assay, but was not altered by increasing cofactor (H2O2). Our results, so far, suggest that the TPO-inhibitory substance may interact reversibly with a specific iodide site on the enzyme or with the oxidized form of iodide, and/or could bind free iodide, making it unavailable for enzymatic oxidation.

Homeless youths: sexual and drug-related behaviour, sexual beliefs and HIV/AIDS risk

Homeless, Anglo-Australian and Greek-Australian 16-year-olds were questioned about their sexual behaviour and sexual beliefs. Measures of sexual risk-taking included type of behaviour, condom use and number of partners. Drug risk was assessed by extent of i.v. drug use, and sharing and cleaning needles. Sexual beliefs included self-perceptions of sexual anxiety, arousal, exploration and commitment. In addition, motivations for engaging in, or avoiding, sex were elicited. The behaviour patterns of homeless adolescents placed them at considerable risk of HIV infection for both sexual and drug risk, and significantly more so than their home-based peers. Gender stereotypic self-perceptions were reported, and homeless and Anglo-Australian youths demonstrated a more masculine style in their self-perceptions than were Greek-Australians. Preferred motivations for sex differed, with homeless youths less concerned about the consequences of sex and more with self-gratification than the home-based adolescents. For homeless girls, higher levels of sexual risk were predicted by perceptions of greater arousal and by less concern about the consequences of sexual activity. Implications for targeted interventions are discussed.

A randomized, double-blind, placebo-controlled trial of ketoconazole 2% shampoo versus selenium sulfide 2.5% shampoo in the treatment of moderate to severe dandruff

BACKGROUND

Ketoconazole is highly effective against the yeast Pityrosporum ovale, an organism believed to be involved in the pathogenesis of dandruff.

OBJECTIVE

Our purpose was to evaluate the safety and effectiveness of ketoconazole 2% shampoo versus selenium sulfide 2.5% shampoo and placebo shampoo in patients with moderate to severe dandruff.

METHODS

Features assessed included adherent and loose dandruff scores, presence or absence of irritation, itching, yeast cells, and global improvement rating by the investigator.

RESULTS

A total of 246 patients were included. Mean total adherent dandruff score declined throughout the treatment period with both ketoconazole 2% and selenium sulfide 2.5% shampoos significantly better than placebo at all visits. Ketoconazole was statistically superior to selenium sulfide at day 8 only (p = 0.0026). Both medicated shampoos were significantly better than placebo for reducing irritation and itching. Of the nine adverse experiences reported during the treatment phase, all involved patients treated with selenium sulfide 2.5% shampoo.

CONCLUSION

Both ketoconazole 2% shampoo and selenium sulfide 2.5% shampoo are effective in the treatment of moderate to severe dandruff; however, ketoconazole 2% shampoo appears to be better tolerated.

Gorham's massive osteolysis: the role of radiation therapy and a review of the literature

PURPOSE

This paper reviews the natural history and management of patients with Gorham's disease and presents four cases treated at The Massachusetts General Hospital since 1965. Gorham's disease is characterized by localized endothelial proliferation which results in destruction and resorption of bone. The etiology is undefined. There is no evidence of a malignant, neuropathic, or infectious component. This disease is progressive in most patients, but in occasional instances the process has been noted to be self-limited. The principal treatment modalities are surgery and radiation therapy.

METHODS AND MATERIAL

Since 1965, four patients with Gorham's Disease have been treated at the Massachusetts General Hospital. Three received definitive radiation therapy in doses ranging from 31.5 to 45 Gy. The fourth patient underwent surgery primarily.

RESULTS

Three patients are currently alive and fully functional with no evidence of disease at last follow-up. The fourth patient died of progressive disease despite treatment with both radiation therapy and surgery.

CONCLUSION

The prognosis for patients with Gorham's disease is generally good unless vital structures are involved. Due to the rarity of this entity, there is no standard therapy. Definitive radiation therapy in moderate doses (40-45 Gy in 2 Gy fractions) appears to result in a good outcome and few long-term complications.

Angioscope-assisted endovascular occlusion of venous tributaries: preclinical studies

The feasibility of angioscope-assisted occlusion of venous tributaries from within a vein using a steerable 'shaped-memory' nickel-titanium (nitinol) alloy catheter and occlusion coils was evaluated. An initial series of tests was designed to establish the necessary pressure (275 p.s.i., 1897.5 kPa), time (1.5 s) and volume (2.5 ml normal saline) requirements for hydraulic delivery of platinum occlusion coils from the nitinol catheter through a 3-Fr tracking catheter. In a second series, 25 side branches of the saphenous vein in 11 amputated limbs were visualized angioscopically and cannulated with the nitinol catheter under angioscopic and fluoroscopic surveillance to determine whether the catheter tip could be positioned and coils deployed. In a third series of studies, ten canine femoral vein tributaries were successfully cannulated with an 8-Fr nitinol catheter and 19 occlusion coils delivered under angioscopic surveillance. Fluoroscopy verified coil placement and all embolized venous tributaries were thrombosed. An ideal approach for femoropopliteal in situ saphenous vein bypass would allow the surgeon to divide saphenous vein valves while occluding venous side branches from within the saphenous vein. These initial studies demonstrate that the nitinol catheter can occlude venous tributaries from within a vein by coil embolization. Further development of this technique for clinical investigation is warranted.

Complications of laparoscopic herniorrhaphy

Anterior inguinal hernia repair is the second-most-commonly performed abdominal operation and has been associated with low morbidity and mortality rates. The principle of laparoscopy has been applied to this surgical problem in a series of 762 patients with 841 inguinal hernias. Four types of laparoscopic repairs were conducted: (1) high ligation of the indirect inguinal hernia sac and closure of the internal ring (87 patients with 89 hernias); (2) plug and patch of the internal ring (74 patients with 87 hernias); (3) transperitoneal suture repair of the transversalis fascia to the iliopubic tract or Cooper's ligament (28 patients with 30 hernias); and (4) placement of a large prosthesis over the myopectoneal orifice (563 patients with 635 hernias). These early results indicate that the overall complication rates were low, especially when a large prosthesis was used to reinforce the myopectoneal orifice. It is concluded that laparoscopic inguinal herniorrhaphy is a safe and effective procedure with which to manage this surgical problem.

Use of percutaneous stitches in laparoscopic mesh hernioplasty

Sutures placed percutaneously have considerably facilitated the accurate intraperitoneal laparoscopic placement of synthetic mesh in the groin. The mesh effectively covers the abdominal wall defect, preventing further herniations in the area.

Identification of control elements 3' to the human keratin 1 gene that regulate cell type and differentiation-specific expression

To define DNA regulatory elements that mediate the response of the keratin 1 (K1) gene to Ca(2+)-induced differentiation, regions spanning the 5'- and 3'-flanking sequences, coding regions, and introns from the human K1 gene were cloned into vectors containing the chloramphenicol acetyltransferase (CAT) reporter gene and transfected into cultured mouse keratinocytes. A 4.3-kilobase (kb) region located 3' to the K1 gene stimulated CAT activity in response to increasing Ca2+ concentrations from 0.05 mM (basal cells) to 1.2 mM (differentiated cells). The 4.3-kb fragment was also active in human epidermal cells but inactive in NIH 3T3 cells and primary mouse fibroblasts. Deletion analysis localized the activity to the terminal 1682 base pairs (bp) of the flanking sequence which retained Ca2+ sensitivity in epidermal cells but was not active in mesenchymal cells. Removal of a 207-base pair element created an enhancer which was active in both epidermal and mesenchymal cells but was still Ca(2+)-inducible. Further deletions identified two elements which functioned synergistically to give maximal Ca(2+)-sensitive activity. Stably transfected epidermal cell lines expressed CAT under the direction of these elements when grafted onto nude mice to reconstitute an intact epidermis. Previously reported keratin regulatory motifs were not contained in the 1682-bp fragment, but an AP-1 site was identified in one of the synergistic subunits.

Laparoscopic colonic procedures

With the advent and general acceptance of laparoscopy as a means of surgically treating intraabdominal disease processes, procedures on organs other than the gallbladder and female genital tract have slowly evolved. After developing basic techniques in an animal model, a clinical series (n = 19) of laparoscopic procedures for a variety of colonic lesions was undertaken and is herein presented. It included both malignant and nonmalignant disease processes and has carried an acceptable complication rate and survival. The average age of our patients was 68, and except for two extended postoperative hospitalizations and one death for non-procedure-related complications, the patients were generally ready for discharge in less than 96 hours. Our current techniques and indications for laparoscopic colonic surgery are detailed.

Laparoscopic colectomy

Fifty-one laparoscopic colectomies were attempted at two institutions. The clinical results and methods are presented. Seven cases (14%) were converted to facilitated procedures, and four cases (8%) were converted to "open." Cases of cancer, diverticulitis, endometriosis, regional enteritis, villous adenomas, and sessile polyps were operated. Right, transverse, left, low anterior, and abdominoperineal colectomies were performed. Colotomies and wedge resections were also performed. Laparoscopic suturing was required in five cases of incomplete anastomosis by circular stapler (18%). Suturing was required in all right, transverse colectomies and colotomies. Operative time averaged 2.3 hours. Hospitalization averaged 4.6 days. Four patients had complications (8%), and one 95-year-old died of pneumonia (2%). Laparoscopic colectomies can be performed safely, but require two-handed laparoscopic coordination, as well as suturing and knot-tying skills.