Superfluid liquid helium control for the primordial inflation polarization explorer balloon payload

The Primordial Inflation Polarization Explorer (PIPER) is a stratospheric balloon payload to measure the polarization of the cosmic microwave background. Twin telescopes mounted within an open-aperture bucket dewar couple the sky to bolometric detector arrays. We reduce detector loading and photon noise by cooling the entire optical chain to 1.7 K or colder. A set of fountain-effect pumps sprays superfluid liquid helium onto each optical surface, producing helium flows of 50-100 cm³ s^-1 at heights up to 200 cm above the liquid level. We describe the fountain-effect pumps and the cryogenic performance of the PIPER payload during two flights in 2017 and 2019.

The balloon-borne cryogenic telescope testbed mission: Bulk cryogen transfer at 40 km altitude

The balloon-borne cryogenic telescope testbed is a stratospheric balloon payload intended to develop technology for a future cryogenic suborbital observatory. A series of flights are intended to establish ultra-light dewar performance and open-aperture observing techniques for large (3 m-5 m diameter) cryogenic telescopes at infrared wavelengths. An initial flight in 2019 demonstrated bulk transfer of liquid nitrogen and liquid helium at stratospheric altitudes. An 827 kg payload carried 14 l of liquid nitrogen (LN2) and 268 l of liquid helium (LHe) in pressurized storage dewars to an altitude of 39.7 km. Once at float altitude, liquid nitrogen transfer cooled a separate, unpressurized bucket dewar to a temperature of 65 K, followed by the transfer of 32 l of liquid helium from the storage dewar into the bucket dewar. Calorimetric tests measured the total heat leak to the LHe bath within the bucket dewar. A subsequent flight will replace the receiving bucket dewar with an ultra-light dewar of similar size to compare the performance of an ultra-light design dewar to that of conventional superinsulated dewars.

ID: 132: LUPUS KERATINOCYTES ARE PRIMED BY AN AUTOCRINE TYPE I INTERFERON LOOP TO ROBUSTLY SECRETE IL-6

Background

Cutaneous lupus erythematosus (CLE) is a disfiguring disease that can affect up to 70% of patients with systemic lupus. Treatment modalities are often ineffective and flares are frequent. Interleukin-6 (IL-6) is a pro-inflammatory cytokine which has gotten recent attention in SLE as IL-6 is increased in the serum of active patients and blockade of IL-6 is therapeutic in murine lupus models and phase I human trials. The source of IL-6 in CLE remains unclear.

Methods

All studies were approved by the University of Michigan Internal Review Board (IRB# 72843 and 66116 to JMK). RNA was isolated from formalin fixed, paraffin-embedded biopsies of CLE rashes, which were obtained from the University of Michigan Pathology database. Real-time PCR was used to determine the expression level of the myxovirus (influenza virus) resistance 1 (MX-1) and interleukin-6 (IL6) genes. Biopsies were stained for IL-6 using immunohistochemistry. Skin biopsies were obtained from uninvolved skin of SLE patients with a history of cutaneous involvement or healthy controls followed by isolation and culture of keratinocytes. At confluence, cultures were treated with various concentrations of TLR ligands or UVB and IL-6 release was measured via ELISA. Blockade of type I IFN signaling was completed via monoclonal antibody to the type I IFN receptor.

Results

Real-time PCR analysis of subacute cutaneous lupus erythematosus (sCLE) (n=21) and discoid (DLE) (n=22) rashes demonstrated a significant upregulation of both the IFN-regulated gene, MX1, and the pro-inflammatory cytokine IL-6 when compared with control samples (n=9). Immunohistochemical analysis of skin biopsies confirmed upregulation of IL-6 in the epidermis when compared to control. Keratinocytes from healthy skin of lupus patients produced significantly more IL-6 when stimulated by TLR2, 3 or 4 agonists or exposed to UVB radiation when compared to identical passage keratinocytes from healthy controls. Treatment of control keratinocytes with IFNα increased their IL-6 production and blockade of type I IFNs in the culture media of SKE keratinocytes downregulated the secretion of IL-6.

Conclusions

IL-6 is increased at the RNA and protein level within cutaneous lupus biopsies when compared to healthy control skin. Keratinocytes are a major producer of IL-6 in the skin and lupus keratinocytes have enhanced production of IL-6 in response to TLR ligands and UV radiation. Exposure to type I IFN can increase IL-6 production in keratinocytes. SLE-derived keratinocytes downregulate IL-6 production in the presence of tonic blockade of the type I IFN receptor. These data suggest that the epidermis, which is an important barrier for environmental insults, is primed for IL-6 production by autocrine type I IFN production and that this may be one mechanism by which factors such as UV exposure may trigger rash development. Further investigations should focus on the pathogenic significance of IL-6 upregulation in the skin and whether targeting this pathway will have an impact on cutaneous disease activity.

Enforced expression of Simian virus 40 large T-antigen leads to testicular germ cell tumors in zebrafish

Testicular germ cell tumors (TGCTs) are the most common malignancy in young men. However, there are few in vivo animal models that have been developed to study this disease. We have used the pufferfish (fugu) lymphocyte-specific protein tyrosine kinase (flck) promoter, which has been shown to enforce high-level expression in the testes of transgenic mice, to express Simian virus 40 large T-antigen in zebrafish testes. Zebrafish that express T-antigen develop TGCTs after a long latency of >1 year. Although overt TGCTs are only evident in 20% of the fish, occult TGCTs can be detected in 90% of the transgenic fish by 36 month of age. The TGCTs resemble the human disease in terms of morphology and gene expression pattern, and can be transplanted to healthy wild-type recipient fish. In addition, enforced expression of the zebrafish stem cell leukemia (scl) gene in the zebrafish testes also generated TGCTs in transgenic fish. These results demonstrate the feasibility of studying TGCTs in a model organism.

Investigation of a mumps outbreak among university students with two measles-mumps-rubella (MMR) vaccinations, Virginia, September-December 2006

Following the clinical diagnosis of the first case of mumps on September 22, 2006 at the University of Virginia (UVA), 52 suspected cases were identified through active surveillance for mumps by the end of December 2006. Samples were collected from 47 students who presented with parotitis despite a documented history of two doses of measles, mumps, and rubella (MMR) vaccine. Six of 47 serum samples (13%) were positive for mumps IgM, and 46/47 specimens were positive for mumps IgG. Endpoint titration of acute phase serum samples from laboratory-confirmed cases did not provide evidence that elevated serum IgG is a consistent marker for infection among cases due to secondary vaccine failure. Buccal swab samples from 39 of the 47 students were tested by real-time reverse transcription-polymerase chain reaction (RT-PCR) and/or viral culture. Mumps virus or mumps RNA was detected in 12 of 39 buccal samples (31%). Genetic analysis of the virus from the outbreak at UVA indicated that the outbreak was not linked to the large mumps outbreak in the Midwestern US that occurred earlier in 2006. Our findings support the use of viral detection to improve laboratory diagnosis of mumps among persons who have received two doses of MMR.

Treatment of hidradenitis suppurativa with infliximab in a patient with Crohn's disease

BACKGROUND

Hidradenitis suppurativa is a chronic, inflammatory, scarring disease characterized by recurrent flares. Recently, a group of 'autoinflammatory disorders' has been described. These disorders are characterized by recurrent inflammatory episodes not mediated by autoantibodies or antigen-specific T-cells. Some of these autoinflammatory disorders have been successfully treated with anti-tumor necrosis factor antibodies.

OBSERVATIONS

We describe a patient with hidradenitis suppurativa and a history of inactive Crohn's disease who was treated with infliximab, with subsequent improvement in her skin disease.

CONCLUSIONS

This case suggests that infliximab may be effective in the treatment of hidradenitis suppurativa in association with Crohn's disease. We also suggest that hidradenitis suppurativa may be closely linked with this new group of autoinflammatory disorders.

Acanthamoeba infection in a patient with chronic graft-versus-host disease occurring during treatment with voriconazole

We report a case of disseminated infection with Acanthamoeba in a patient with graft-versus-host disease after hematopoietic stem cell transplant (HSCT) for acute lymphocytic leukemia. The infection involved the brain, skin, and lungs and occurred despite treatment with voriconazole for mold prophylaxis, and did not respond to treatment with multiple other agents reported to have activity against Acanthamoeba. To our knowledge, infection with Acanthamoeba has been reported in 4 other patients after HSCT or bone marrow transplant, and our case is the first to be diagnosed ante-mortem.

Percutaneous endoscopic gastrostomy with T-bar fixation in children and infants

BACKGROUND

The standard for placement of pediatric gastrostomy tubes has been percutaneous endoscopic gastrostomy (PEG) using the Ponsky "pull" technique. This study evaluated the safety and efficacy of PEG placement using the "push" technique with T-bar fixation in pediatric patients. This technique generally is limited to the adult population. With this technique, endoscopy is performed. The stomach is insufflated, and the anterior abdominal wall is transilluminated. T-bar fasteners are sequentially deployed to secure the stomach to the anterior abdominal wall. Using a modified Seldinger technique, a gastrostomy tube is placed through the center of the T-bars.

METHODS

A retrospective review of all PEG tubes placed in pediatric patients from 1997 to 2003 using the T-bar gastroscopy "push" technique was conducted. Patients 18 years of age or younger were included in the study. Data collected included patient age, operative time, procedure location, and complications.

RESULTS

The procedure was performed for 47 children (mean age, 6.4 years), including 15 infants younger than 1 year. The indications for long-term enteral access included failure to thrive (n = 11), feeding disorder secondary to neurologic dysfunction (n = 31), gastroparesis (n = 1), and dysphagia (n = 4). The operative time averaged 23 min (range, 12-45 min). One major complication occurred (gastrocolonic fistula). The one minor complication was early dislodgement of the gastrostomy tube, which required replacement.

CONCLUSION

This study found the described technique to be safe and effective for the placement of gastrostomy tubes in infants and children.

Rhinoconjunctivitis in 5-year-old children: a population-based birth cohort study

BACKGROUND

There is a paucity of data on the prevalence, risk factors and natural history of rhinitis in early childhood.

OBJECTIVE

Within the context of a whole-population birth cohort we investigated the prevalence of and risk factors for current rhinoconjunctivitis (CRC) at age 5 years.

METHODS

Children were followed prospectively to age 5 years [questionnaires (n = 815), skin testing (n = 717), specific immunoglobulin E (n = 478), lung function (n = 711), dry air challenge (n = 556)]. Endotoxin and allergen exposures were measured in dust samples.

RESULTS

The prevalence of rhinitis ever, current rhinitis and rhinoconjunctivitis was 28.2%, 26.1%, and 12.1%, respectively. Asthma, wheeze and eczema coexisted with CRC (P < or = 0.01). In a multivariate model, maternal asthma (OR 2.38, 95% CI: 1.30-4.38, P = 0.005), paternal hay fever (1.96, 1.11-3.46, P = 0.02) and sensitization to grass (3.46, 1.86-6.42, P < 0.001) and cat (2.42, 1.14-5.18, P = 0.02) remained significant and independent associates of CRC. Whilst almost half of children with CRC were nonatopic, there was little difference in risk factors between atopic and nonatopic CRC. Amongst children with current wheeze, the presence of concurrent CRC had no effect on either severity or frequency of wheezy episodes. There was no difference in specific airway resistance, forced expiratory volume in 1 second (FEV(1)) or airway reactivity between children with and without CRC after adjustment for the presence of wheeze.

CONCLUSION

Family history of allergic disease and sensitization to inhalant allergens are risk factors for rhinoconjunctivitis in preschool children. In this age group, there is no association between the presence of rhinoconjunctivitis and severity of wheeze, increased airway reactivity and reduced lung function.

Dysplastic naevi with moderate to severe histological dysplasia: a risk factor for melanoma

BACKGROUND

The risk of malignant melanoma associated with histologically dysplastic naevi (HDN) has not been defined. While clinically atypical naevi appear to confer an independent risk of melanoma, no study has evaluated the extent to which HDN are predictive of melanoma.

OBJECTIVES

To estimate the risk of melanoma associated with HDN. Secondarily, the risk associated with number of naevi and large naevi is estimated.

METHODS

We enrolled 80 patients with newly diagnosed melanoma along with 80 spousal controls. After obtaining information on melanoma risk factors and performing a complete cutaneous examination, the most clinically atypical naevus was biopsied in both cases and controls. Histological dysplasia was then assessed independently by 13 dermatopathologists (0, no dysplasia; 1, mild dysplasia; 2, moderate dysplasia; 3, severe dysplasia). The dermatopathologists were blinded as to whether the naevi were from melanoma subjects or controls. Multivariate analyses were performed to determine if there was an independent association between the degree of histological dysplasia in naevi and a personal history of melanoma.

RESULTS

In persons with naevi receiving an average score of > 1 (i.e. naevi considered to have greater than mild histological dysplasia), there was an increased risk of melanoma [odds ratio (OR) 2.60, 95% confidence interval (CI) 0.99-6.86] which persisted after adjustment for confounders (OR 3.99, 95% CI 1.02-15.71). Very few dermatopathologists reliably graded naevi of subjects with melanoma as being more dysplastic than naevi of control subjects. Among the entire group, the interobserver reliability associated with grading histological dysplasia in naevi was poor (weighted kappa 0.28).

CONCLUSIONS

HDN do appear to confer an independent risk of melanoma. However, this result may add more to our biological understanding of melanoma risk than to clinical assessment of risk, because HDN assessed by a single pathologist generally cannot be used to assess risk of melanoma. Future studies should be directed at establishing reproducible, predictive criteria for grading naevi.

The prospective, randomized investigation of the safety and efficacy of telmisartan versus ramipril using ambulatory blood pressure monitoring (PRISMA I)

OBJECTIVE

To compare the efficacy and safety of once-daily telmisartan and ramipril on blood pressure (BP) reductions during the last 6 h of the dosing interval.

PATIENTS AND METHODS

In a prospective, randomized, open-label, blinded-endpoint study using ambulatory BP monitoring, 801 patients with mild-to-moderate hypertension were randomly assigned to once-daily treatment with telmisartan 80 mg for 14 weeks or ramipril 5 mg for 8 weeks and then force titrated to ramipril 10 mg for the last 6 weeks. Primary endpoints were the reduction from baseline in the last 6-h mean ambulatory systolic BP (SBP) and diastolic BP (DBP). Secondary endpoints included changes in 24-h, morning, daytime and night-time mean ambulatory BP and ambulatory BP response rates.

RESULTS

Telmisartan 80 mg produced greater reductions in the last 6-h mean ambulatory SBP and DBP compared with ramipril 5 mg (P < 0.0001) and 10 mg (P < 0.0001), and was superior to ramipril for all secondary ambulatory SBP and DBP endpoints (P < 0.05). Ambulatory BP response rates (24-h mean ambulatory SBP/DBP < 130/80 mmHg or reduction from baseline > or = 10 mmHg) were greater with telmisartan 80 mg (P < 0.01) than with ramipril 5 and 10 mg. Ramipril was associated with a higher incidence of treatment-related cough (5.7 versus 0.5% for telmisartan).

CONCLUSIONS

Telmisartan was significantly more effective than ramipril in reducing BP throughout the 24-h dosing interval and particularly during the last 6 h, a time when patients appear to be at greatest risk of cerebro- and cardiovascular events. Both drugs were well tolerated, although ramipril was associated with a higher incidence of cough.

Inhaled ethanolic and aqueous solutions via Respimat Soft Mist Inhaler are well-tolerated in asthma patients

BACKGROUND

Respimat Soft Mist Inhaler (SMI) is a new-generation inhaler offering improved lung deposition compared with other devices. Bronchodilators administered via Respimat SMI are preserved and stabilized with benzalkonium chloride (BAC) and ethylene diamine tetra-acetic acid (EDTA); both have been reported to cause paradoxical bronchoconstriction if a threshold dose is exceeded.

OBJECTIVE

The aim of this randomized, double-blind, three-period, crossover study was to establish that the safety of inhaled ethanolic and aqueous placebo solutions (containing BAC and EDTA) is equivalent to that of inhaled normal saline solution when administered to asthma patients via Respimat SMI.

METHODS

Thirty-seven asthma patients with airway hyper-reactivity were randomized to receive four actuations of each of the following three treatments via Respimat SMI, one on each of 3 study days: ethanolic placebo (12 microl 96% ethanol + 0.13 mug EDTA/actuation), aqueous placebo (12 microl water + 5.5 microg EDTA + 1.1 mug BAC/actuation), and normal saline (12 microl 0.9% sodium chloride/actuation). Pulmonary function tests were performed at baseline and at 5, 15, 30, 60, 120 and 180 min after inhalation; the primary endpoint was the lowest FEV(1) recorded between 0 and 30 min.

RESULTS

The mean lowest FEV(1) recorded between 0 and 30 min after inhalation minus the study day baseline was -0.090 litres for ethanolic placebo, -0.121 litres for aqueous placebo and -0.094 litres for normal saline (SEM 0.034 litres for all). The mean treatment differences were: ethanolic placebo versus normal saline 0.004 litres (90% CI -0.075-0.083 litres, p = 0.002), and aqueous placebo versus normal saline -0.028 litres (90% CI -0.107-0.052 litres, p = 0.006). Since both 90% CIs fell within the pre-determined equivalence region of +/-0.15 litres, both treatments were considered equivalent to normal saline.

CONCLUSION

Ethanolic and aqueous solutions administered via Respimat SMI are safe with regard to paradoxical bronchoconstriction in asthma patients with airway hyper-reactivity.

A comparison of North American and European conceptualizations of clinical supervision

Examination of the extant North American and European substantive literature indicates two differing conceptualizations of the purpose and resultant practice of clinical supervision (CS). The North American conceptualization creates the need for all supervisors to be more "expert" in the particular speciality of nursing than the supervisee, and this paper explores some of the hitherto unanswered issues arising from this. The European conceptualization posits supervision as a forum for considering the personal, interpersonal, and clinical aspects of care so as to develop and maintain nurses who are skilled and reflective practitioners. This situation creates the need for supervisors to be effective at supporting nurses in self-monitoring, identifying difficulties in practice, and finding the proper place to make good the deficit, not necessarily to be more expert in the particular nursing speciality.

Reported versus confirmed wheeze and lung function in early life

AIMS

To investigate the relation between parentally reported wheeze (unconfirmed), physician confirmed wheeze, and subsequent lung function.

METHODS

Children at risk of allergic disease (one parent atopic) were recruited antenatally and followed prospectively from birth. During the first three years of life parents were asked to contact the study team if their child was wheezy. The presence of wheeze was confirmed or not by the primary care or study physician. Respiratory questionnaire and specific airway resistance measurement (sR(aw), body plethysmograph) were completed at age 3 years.

RESULTS

A total of 454 children were followed from birth to 3 years of age. One hundred and eighty six (40.9%) of the parents reported their child wheezing in the first three years of life, and in 130 (28.6%) the wheeze was confirmed. A total of 428 children attended the three year clinic review, of whom 274 (64%) successfully carried out lung function tests. There was no significant difference in sR(aw) (kPa.s; geometric mean, 95% CI) between children who had never wheezed (n = 152; 1.03, 1.00 to 1.06) and those with a parentally reported but unconfirmed wheeze (n = 36; 1.02, 0.96 to 1.07, p = 1.00). sR(aw) was significantly higher in children with a physician confirmed wheeze (n = 86; 1.17, 1.11 to 1.22, p < 0.001) compared to those with no history of wheeze or with unconfirmed wheeze.

CONCLUSIONS

Children with physician confirmed wheeze have significantly poorer lung function compared to those with parentally reported but unconfirmed and those who have never wheezed. A proportion of parents may have little understanding of what medical professionals mean by the term "wheeze".

Simultaneous measurement of six cytokines in a single sample of human tears using microparticle-based flow cytometry: allergics vs. non-allergics

Tears play an essential role in maintaining corneal and conjunctival integrity by providing a tightly regulated, optimal extracellular environment critical to its numerous functions, which include anti-microbial defense, wound healing and inflammatory responses such as allergies. Elevated levels of inflammatory cytokines have been reported in tears from various ocular disease states. Characterization of tear cytokines has been limited by the small volume (microliter amounts) attainable. This limitation was addressed with the newly developed Becton Dickinson Cytometric Bead Array (CBA), which combines the principles of the "sandwich" immunoassay with the capability of flow cytometry for simultaneous measurement of the characteristics of multiple particles. This technique allows determination of six human cytokine (IFNgamma, TNFalpha, IL-2, IL-4, IL-5, IL-10) concentrations simultaneously in a single tear sample. Tears were collected from the inferior fornix of non-allergic (n=7) and allergic (n=9) donors. Each tear sample or cytokine standard was incubated with a mixture of capture Ab-bead reagent and detector Ab-phycoerythrin (PE) reagent, and analyzed using flow cytometry. All six cytokines were detectable in both non-allergic and allergic tears. Tears from allergic donors contained significantly less IL-10 (p=0.035), and had significant increases in the ratios of TNFalpha/IFNgamma, IL-5/IFNgamma and IL-5/IL-10 (p=0.0008, 0.0124 and 0.011, respectively). The small volume required (5-10 microl/test) by the Cytometric Bead Array allows measurement of all six cytokines from a single collection of tears. This decreases collection time, minimizing the confounding effect of stimulation on cytokine concentration in tears, as well as allowing calculation of cytokine ratios.

Comparison of acute swelling and function in subjects with lateral ankle injury

STUDY DESIGN

Prospective correlational study involving a convenience sample.

OBJECTIVES

To investigate the relationships among figure-of-eight girth measurements and functional level in patients with acute lateral ankle sprains to determine the appropriate use of these clinical measures.

BACKGROUND

Research has shown that subjective scales of perceived athletic ability and measurements of swelling are useful in assessing clinical improvement following an acute ankle sprain; however, the relationship between ankle swelling and level of function is not known.

METHODS AND MEASURES

Twenty-nine subjects (20 men, 9 women) varying in age from 18-59 years of age (mean age, 30.8 +/- 11.37) with acute lateral ankle sprains were included in this study. Each subject was evaluated by 1 of 3 raters for ankle girth, weight-bearing status, and functional level as determined by a modified Ankle Osteoarthritis Scale (AOS) and the Foot and Ankle Ability Index (FAAI). This study also investigated the relationship between these measures and the sport subscale of the FAAI (FAAI sport). This is an 8-item subscale which includes questions on running, jumping, landing, quick starts and stops, cutting or lateral movements, low impact activities, ability to perform an activity with normal technique, and ability to participate in desired sports.

RESULTS

No significant correlations were found between figure-of-eight girth measurements and functional level. However, we did find moderate to good correlations between the FAAI vs. weight-bearing (rho = 0.73), FAAI vs. AOS (rho = -0.79), FAAI sport vs. weight-bearing (rho = 0.68), FAAI vs. FAAI Sport (rho = 0.73), weight-bearing vs. AOS (rho = -0.57), and FAAI Sport vs. AOS (rho = -0.50).

CONCLUSIONS

The figure-of-eight method is highly reliable and is appropriate for measuring ankle swelling; however, it does not correlate with functional level as determined by the modified AOS, FAAI, or observed weight-bearing status during gait. Therefore, clinicians should refrain from making assumptions about function based on ankle swelling.

Treatment of head and neck melanoma, lentigo maligna subtype: a practical surgical technique

Melanoma with the lentigo maligna histological pattern often provides a significant and difficult challenge to the head and neck surgeon. The lentigo maligna subtype is the most common type of melanoma on the head and neck. This potentially lethal form of cancer is associated with greater nonvisual lesional extension that is often not clinically apparent. Failure to excise the entire lesion results in a higher risk of local recurrence and a poorer prognosis. The staged excision technique described herein results in histological interpretation of 100% of the peripheral margins using formalin-fixed vertical sections. Definitive local excision and soft tissue reconstruction are performed in a subsequent stage, with an assurance that 100% of the peripheral margins have been evaluated and interpreted as free of disease.

The effect of a new tissue-adhesive wound dressing on the healing of traumatic abrasions

BACKGROUND

Octylcyanoacrylate is a new medical-grade adhesive with antimicrobial properties. It forms a thin, flexible, occlusive bandage.

OBJECTIVE

To determine the gross and histological effects of the spray bandage when treating abrasions.

METHODS

Abrasions were produced on the flanks of 18 albino guinea pigs and randomized to treatment with a control (Biobrane) or octylcyanoacrylate dressing. The wounds were assessed with digital photography using a previously validated method. Histopathological analysis was done on day 14.

RESULTS

There were no differences in the mean wound-healing ratios on days 1 (1.25 vs. 1.23, p = 0.61), 7 (1.15 vs. 1.13, p = 0. 14) and 14 (1.03 vs. 1.02, p = 0.63) for tissue adhesive and Biobrane, respectively. There were no differences found on histopathological analysis either.

CONCLUSIONS

This external spray bandage was well tolerated and did not show any signs of histotoxicity or adverse wound healing.

Solitary melanoma confined to the dermal and/or subcutaneous tissue: evidence for revisiting the staging classification

BACKGROUND

Several patients presented with a single focus of presumed cutaneous metastatic melanoma with an unknown primary tumor based on clinical and histologic staging criteria of the American Joint Committee on Cancer (AJCC). This population is classified as having stage IV disease by the current AJCC staging system, which carries a dismal prognosis (5%-18% 5-year survival). Our clinical observation was that these patients had a higher survival rate than would be expected for stage IV disease. We believe this population represents a subgroup of primary dermal- and or subcutaneously-derived melanoma that simulates cutaneous metastatic melanoma in histologic and clinical presentation but may differ in behavior.

OBSERVATIONS

The database records of 1800 patients from the University of Michigan Melanoma Clinic, Ann Arbor, were retrospectively reviewed to identify the prevalence and survival for patients diagnosed with a single focus of presumed metastatic melanoma to the skin based on accepted histologic and clinical parameters. The prevalence of this population was 0.61% (11 of 1800 patients). The Kaplan-Meier 8-year survival estimate was 83% (95% confidence interval, 58%-100%).

CONCLUSIONS

By AJCC convention, these cases are classified as stage IV metastatic disease. Our data suggest that these presumed metastatic tumors do not behave like stage IV metastatic disease to the skin via lymphatic or hematogenous spread from an unknown primary site; rather, they are behaving like primary tumors originating in the dermal and/or subcutaneous tissue.

Perineural spread of basal cell carcinomas treated with Mohs micrographic surgery

BACKGROUND

Perineural spread is a well-documented feature of cutaneous tumors and may portend a more aggressive course. The incidence of perineural invasion in basal cell carcinoma (BCC) is reportedly 1%. The authors sought to determine whether perineural spread occurs more commonly than previously thought.

METHODS

The authors prospectively evaluated 434 patients with BCC treated with Mohs surgery, assessing the presence or absence of perineural inflammation and invasion in tumors requiring more than one stage of surgery. They also documented the demographic features, clinical characteristics, histologic subtype, and operative data in each case.

RESULTS

Seventy-eight BCCs required more than one stage of Mohs surgery. Perineural inflammation, perineural tumor invasion, or both were present in 29 of the 78 tumors (37%), or 6.7% of all 434 prospectively evaluated cases. Twenty-one of the 78 tumors (26.9%) exhibited perineural inflammation, 3 (3.8%) demonstrated perineural invasion, and 5 (6.4%) exhibited both. Tumors with perineural invasion required 5.3 surgical stages on average for clearance, in contrast to tumors without perineural invasion, which required 2.2 stages. Tumors with perineural inflammation, inflammation plus tumor invasion, and invasion alone were, respectively, 138%, 149%, and 194% greater in area preoperatively than tumors without perineural involvement, and their mean defect areas after Mohs surgery were, respectively, 151%, 121%, and 605% larger than those of tumors without perineural involvement.

CONCLUSIONS

The incidence of perineural invasion among cases of BCC appears higher than previously recognized. Tumor aggressiveness appears to correlate with the presence of perineural invasion. Surgery with horizontal frozen-section margin control enables easy detection of perineural involvement and should therefore be strongly considered for the treatment of high risk BCC patients.

Do primary small intestinal melanomas exist? Report of a case

Metastatic melanoma to the gastrointestinal tract is not uncommon with the small intestine representing the most common site of gastrointestinal metastases. The occurrence of primary melanoma of the small intestine, however, is rare. We describe a case of primary melanoma of the small intestine and establish criteria for distinction between primary and metastatic small intestinal melanoma.

Lafora disease: diagnosis by skin biopsy

Lafora disease is a fatal neurometabolic disorder characterized by progressive myoclonic epilepsy. Diagnosis relies upon the discovery of specific inclusion bodies in any of several organs. Dermatologists and dermatopathologists should be familiar with this condition because axillary skin biopsy is useful to diagnose this disorder. We present a case of Lafora disease diagnosed by axillary skin biopsy and review the condition's clinical, histologic, and ultrastructural features.

Isolated extragenital bowenoid papulosis of the neck

We report a case of extragenital bowenoid papulosis (BP) in a healthy immunocompetent 42-year-old man. The lesions occurred on the anterolateral aspects of the neck and were not associated with genital, oral, or periungual lesions. Lesional skin tested positive with the Digene hybrid capture system cocktail assay that identifies infection with a mixture of high to intermediate oncogenic human papillomavirus (HPV) types, including types 16, 18, 31, 33, 35, 45, 51, 52, and 56. This cocktail assay identifies infection with HPV types typically associated with high-grade squamous intraepithelial lesions and invasive carcinoma. This case represents the sixth case of isolated cutaneous BP occurring a significant distance from the genital region.

Clinical, histopathologic, and molecular aspects of cutaneous human papillomavirus infections

Human papillomaviruses comprise a large family of double stranded DNA viruses that are the etiologic agents of benign warts and anogenital cancers. At least 82 different human papillomavirus types have been identified and many remain yet uncharacterized. The development of new molecular techniques in recent years has led to an increased understanding of human papillomaviruses and their roles in carcinogenesis. Several clinicopathologic entities arising from human papillomavirus infection encountered by the dermatologist are the subject of the article. The epidemiology, molecular biology, clinical presentation, histologic findings, and treatment of each disorder, where applicable, is discussed.

Multiple primary melanomas

BACKGROUND

The diagnosis of primary melanoma increases the risk of additional primary melanomas.

OBJECTIVE

We characterize the subgroup of patients with multiple melanomas.

METHODS

We reviewed the melanoma database.

RESULTS

Sixty patients with multiple primary melanomas were identified. Twelve (20%) experienced melanomas in the same regional location, 43 (72%) in different locations, and 5 (8%) in both the same and different locations (> 2 melanomas). Eighteen (30%) were diagnosed concurrently with multiple melanomas, 38 (63%) subsequently, and 4 (7%) concurrently and subsequently (>2 melanomas). Forty-two percent of subsequent melanomas occurred within 3 years of the initial lesion diagnosis, 9 (17%) between 3 and 7 years, and 22 (42%) after more than 7 years. Subsequent melanomas were thinner in 70% of cases (P = .05). The mean age at first melanoma diagnosis was 38 and 59 years, respectively, for those with and without dysplastic nevi (P < .001).

CONCLUSION

In patients with multiple melanomas, subsequent melanomas often occur in different regional locations several years after diagnosis of the initial lesion.

Complete spontaneous regression of pulmonary metastatic melanoma

BACKGROUND

Complete spontaneous regression of melanoma metastatic to the lungs is a rare event.

OBJECTIVE

To report a case of biopsy-proven melanoma metastatic to the lung with complete spontaneous regression.

METHODS

Multidisciplinary case report.

RESULTS

A 35-year-old white female was diagnosed with metastatic melanoma to the lung. A pleural biopsy confirmed the diagnosis. Partial spontaneous regression was noted by a staging computed tomography scan prior to enrollment in an investigational protocol. Complete spontaneous regression occurred over 5 months without any form of conventional or alternative therapy, and the patient remains disease-free 3 years after diagnosis.

CONCLUSIONS

Our case represents the seventh case of complete spontaneous regression of melanoma metastatic to the lung, and the only case with histologic confirmation of both the primary and pulmonary metastatic lesions. The patient was pregnant twice between the time of her initial diagnosis of primary melanoma and pulmonary metastatic disease.

The effect of a rapid sequence induction protocol on intubation success rate in an air medical program

The purpose of this study was to examine the percentage of successful intubations before and after implementation of a rapid sequence induction (RSI) protocol in patients treated by our flight nurses and paramedics. The records of 100 intubation attempts before the RSI protocol was implemented and 98 after implementation were reviewed. Success rate of intubation was 79% in the preRSI patient group and 84.7% in the postRSI group. No significant difference existed in the number of patients successfully intubated preRSI compared with postRSI. The statistically significant patient characteristics associated with unsuccessful intubation were facial trauma, combativeness, vomiting, and nasal bleeding.

Clinical and histologic trends of melanoma

BACKGROUND

Several changing clinical and histopathologic melanoma trends occurred from the 1950s to the 1980s.

OBJECTIVE

The purpose of this study was to evaluate melanoma trends during the past decade and to compare present trends to those documented during the past four decades.

METHODS

Sex, age at diagnosis, location, tumor thickness, stage, and histologic subtypes were evaluated from 1984 to 1995 and compared with trends during the past four decades.

RESULTS

Most changing trends from the past four decades have slowed or stabilized during the past decade.

CONCLUSION

Complete reporting of all melanomas to central tumor registries is necessary to accurately analyze present and future melanoma trends. Ongoing and new prevention and control strategies beginning at birth may be necessary to continue the positive efforts to curtail the melanoma epidemic.

Calciphylaxis: a cause of necrotic ulcers in renal failure

BACKGROUND

Calciphylaxis is a rare and life-threatening condition occurring in patients with end-stage renal disease on dialysis. The diagnosis is frequently delayed or missed and therapy is often unsuccessful.

OBJECTIVE

The clinical and pathological components of calciphylaxis are emphasized in a patient that may facilitate early diagnosis and initiation of therapy.

RESULTS

Early recognition of the clinical signs and symptoms of calciphylaxis is crucial. The tissue diagnosis requires large elliptical biopsies because histological findings are segmental and often missed.

CONCLUSION

Early diagnosis and intervention in calciphylaxis is critical. Parathyroidectomy should be considered in all cases.

Xanthomonas maltophilia infection presenting as erythematous nodules

Xanthomonas (Pseudomonas) maltophilia is increasingly being recognized as an opportunistic pathogen in hospitalized and debilitated patients. We describe X. maltophilia cellulitis in a neutropenic patient undergoing consolidation chemotherapy for acute lymphocytic leukemia. The patient had multiple, erythematous, nonulcerated nodules on the lower extremities. A biopsy specimen showed numerous gram-negative bacilli in the dermis and subcutis, without evidence of vasculitis. Tissue culture and subsequent blood cultures grew X. maltophilia. The cutaneous nodules and positive blood cultures resolved after treatment with intravenous ciprofloxacin and trimethoprim-sulfamethoxazole.

Usefulness of the staged excision for lentigo maligna and lentigo maligna melanoma: the "square" procedure

BACKGROUND

Management of lentigo maligna (LM) and lentigo maligna melanoma (LMM) may present problems because of the characteristic, yet unpredictable, subclinical peripheral and periadnexal extension of atypical junctional melanocytic hyperplasia beyond the visible margins.

OBJECTIVE

We used paraffin-embedded (permanent) peripheral vertical section margin control in a staged fashion in the management of LM and LMM.

METHODS

We used a modification of surgical excision in a staged fashion by means of a two-bladed knife with permanent peripheral vertical section margin control.

RESULTS

This method is technically easy and results in complete histologic evaluation of the peripheral margins without compromising the measurement of tumor thickness of the primary melanoma.

CONCLUSION

The use of the "square" procedure, a staged excision with permanent peripheral vertical section margin control, is useful in the management of LM and LMM.

A surgical wound infection due to Mycobacterium chelonae successfully treated with clarithromycin

BACKGROUND

Mycobacterium chelonae is an uncommon but recognized cause of chronic localized cutaneous infection at a site of penetrating trauma or a surgical wound.

OBJECTIVE

The problem faced by physicians encountering an infection by M. chelonae is often response to therapy, which may be highly variable.

METHODS

We describe an immunocompetent patient who developed a localized infection due to M. chelonae following surgery for a basal cell carcinoma of the lower leg.

RESULTS

The infection responded to treatment with clarithromycin.

CONCLUSION

The clinical efficacy of clarithromycin and the salient features of M. chelonae infection and its treatment are discussed.

Mucinous carcinoma of the skin

Primary mucinous carcinoma of the skin is a rare adnexal neoplasm with sweat gland differentiation. We describe a case of primary mucinous carcinoma of the skin and characterize its clinical and histologic features. Mucinous carcinoma can occur in noncutaneous visceral sites and may metastasize to the skin. Thus it is important to exclude the possibility of a noncutaneous visceral primary tumor before diagnosing primary mucinous carcinoma of the skin.