耳廓瘢痕疙瘩综合治疗的临床观察

目的评价手术联合曲安奈德局部注射治疗耳廓瘢痕疙瘩的临床效果。方法对12例(20侧)患者采用部分或全部切除耳廓瘢痕,皮瓣恢复耳廓正常外形。术后10 d切口及残余瘢痕内注射曲安奈德注射液,曲安奈德10~20 mg以2%利多卡因稀释1倍后注射,每2周1次,视瘢痕消退情况逐渐撤药。结果随访6~36个月,治愈8例,显效4例,有效率100%,疗效满意。结论手术联合曲安奈德局部注射是治疗耳廓瘢痕疙瘩的有效方法。     

Sofosbuvir and Daclatasvir Combination Therapy in a Liver Transplant Recipient With Severe Recurrent Cholestatic Hepatitis C

Recurrent HCV infection following liver transplantation can lead to accelerated allograft injury that is difficult to treat with interferon. The aim of this study is to describe the first ever use of an interferon‐free, all oral regimen in a liver transplant recipient with severe recurrent HCV. A 54‐year‐old male with HCV genotype 1b developed severe cholestatic HCV at 6 months posttransplant with ascites, AST 503 IU/mL, alkaline phosphatase of 298 IU/mL, HCV RNA of 12 000 000 IU/mL, and histological cholestasis with pericellular fibrosis. Sofosbuvir, an HCV polymerase inhibitor (400 mg/day), and daclatasvir, an HCV NS5A replication complex inhibitor (60 mg/day), were co‐administered for 24 weeks. Within 4 weeks of initiating treatment, serum HCV RNA levels became undetectable and liver biochemistries normalized with concomitant resolution of ascites. The patient achieved a sustained virological response with undetectable HCV RNA at 9 months posttreatment. During and following treatment, the daily dose and blood level of tacrolimus remained stable and unchanged. The rapid and sustained suppression of HCV replication in this liver transplant recipient provides great promise for the use of combination oral antiviral regimens in other immunosuppressed and interferon refractory HCV patients.     

Large Recurrent Phyllodes Tumour

This is a case report of 45-year-old woman with recurrent phyllodes tumour. Although these tumours are not very rare and one finds them occasionally in day-to-day practice, we report here a case of recurrent phyllodes tumour that was treated by a simple mastectomy 1 year back, and it recurred very fast and attained enormous dimensions without any local ulceration.     

New Combination of Triamcinolone, 5-Fluorouracil, and Pulsed-Dye Laser for Treatment of Keloid and Hypertrophic Scars

BACKGROUND: Keloids and hypertrophic scars are benign growths of dermal collagen that usually cause major physical, psychological, and cosmetic problems. METHODS: In this 12-week single-blinded clinical trial, 69 patients were randomly assigned into three study groups. In Group 1, intralesional triamcinolone acetonide (TAC, 10 mg/mL) was injected at weekly intervals for a total of 8 weeks. In Group 2 [TAC+5-fluorouracil (5-FU)], 0.1 mL of 40 mg/mL TAC was added to 0.9 mL of 5-FU (50 mg/mL). This combination was injected weekly for 8 weeks. In Group 3, in addition to weekly TAC+5-FU injection for 8 weeks, lesions were irradiated by 585-nm flashlamp-pumped pulsed-dye laser (PDL, 5-7.5 J/cm2) at the 1st, 4th, and 8th weeks. Lesions were assessed for erythema, pruritus, pliability, height, length, and width. RESULTS: Sixty patients completed the study. At the 8- and 12-week follow-up visits, all groups showed an acceptable improvement in nearly all measures, but in comparison between groups, these were statistically more significant in the TAC+5-FU and TAC+5-FU+PDL groups (p<.05 for all). At the end of the study, the erythema score was significantly lower, and itch reduction was statistically higher in the TAC+5-FU+PDL group (p<.05 for both). Good to excellent improvements (>50% improvement) were reported by the patients as follows: 20% in Group 1, 55% in Group 2, and 75% in Group 3, all of which were significantly different (p<.05). Good to excellent responses were reported by the blinded observer as follows: 15% in Group 1, 40% in Group 2, and 70% in Group 3. Their differences were statistically significant (p<.05). Atrophy and telangiectasia were seen in 37% of patients in TAC group. CONCLUSION: Overall efficacy of TAC+5-FU was comparable with TAC+5-FU+PDL, but the TAC+5-FU+PDL combination was more acceptable by the patients and produced better results. Its effect on lightening of the lesion was promising. The TAC+5-FU+PDL combination seems to be the best approach for treatment of keloid and hypertrophic scars.     

Use of Intralesional Cryosurgery as an Innovative Therapy for Keloid Scars and a Review of Current Treatments

Keloids are benign growths characterized by excessive collagen formation. The treatment of keloid scars remains a challenging clinical dilemma for both patients and providers. Intralesional cryosurgery has emerged as a safe and effective new treatment by destroying the hypertrophic scar tissue with minimal damage to the skin surface.Keloids are benign, dermal, fibroproliferative tumors characterized by excess collagen at the site of previous skin injury. Keloid scars extend beyond the borders of the original wound in contrast to hypertrophic scars, which are limited to the original wound site. Keloids often develop soon after injury, but can also occur up to several years following the initial traumatic insult.1Keloid scars are well-demarcated, rubbery, mildly tender, bosselated tumors with a shiny surface, often marked by telangectasias and sometimes ulcerations. Lesions are pink to purple in color and may display hyperpigmentation. The most common anatomic sites include the anterior chest, shoulders, ear lobes, cheeks, and skin overlying joints. After development, keloid lesions continue to persist without spontaneous regression and have no malignant potential. Patients often complain of pruritis, pain, and hyperesthesia. These symptoms, along with the contractures from excessive scar formation, can be extremely uncomfortable for patients.2,3A histological examination of a keloid reveals larger, thicker, and more disorganized collagen fibers than those seen in normal skin.1 They are pale-staining, hypocellular type I and III collagen bundles that lack nodules. Blood vessels are scattered and dilated, contributing to the poor vascularization in keloid scars. Special stains can detect the overproduction of fibronectin, an extracellular matrix protein.2Excessive scar formation is due to abnormal wound healing following any injury to the deep dermis. Common causes include surgical procedures, piercings, vaccinations, lacerations, and burn injuries. Normal wound healing depends on the fine balance between extracellular matrix deposition and degradation.2 Over expression of fibroblast-specific growth factors has been implicated in the pathogenesis of keloids; these molecules include vascular endothelial growth factor (VEGF), transforming growth factor-beta (TGF-β), connective tissue growth factor (CTGF), and platelet-derived growth factor (PDGF). Additionally, keloid scars endure a longer inflammatory period compared to other scars, during which immune cells and pro-inflammatory cytokines continue to stimulate fibroblasts.2,3 Due to these aberrations and imbalances between the anabolic and catabolic phases of wound healing, there is exaggerated fibroblast activity and ultimately increased collagen synthesis.1,3The likelihood of developing a keloid scar is multifactorial with a strong genetic component. There is potential for all individuals (except albinos) to develop keloid scars; however, the greatest incidence is observed in patients of darker skin color. Keloids are most common in the second to third decades of life, and susceptibility decreases with age.2,3     

Recurrent Male Breast Cancer Accompanied by Carcinomatous Pleuritis That Responded to Combination Therapy with High-Dose Toremifene and Docetaxel

BACKGROUND: Male breast cancer (MBC) is a rare disease with no standard treatment compared to female breast cancer. There are very few reports that go beyond second-line chemotherapy and endocrine therapy for advanced and recurrent MBC. CASE REPORT: This report presents a case of recurrent MBC accompanied by carcinomatous pleuritis that responded to combination therapy with high-dose toremifene (TOR) and docetaxel (DOC). A 63-year-old male patient had previously undergone a modified radical mastectomy for left breast cancer and received several series of systemic chemotherapy and endocrine therapy. He complained of severe dyspnea, and was admitted to our hospital due to a massive left pleural effusion caused by carcinomatous pleuritis. He received combination therapy with high-dose TOR and biweekly DOC. The pleural effusion disappeared without any severe side effects after 4 cycles of the therapy. Thereafter, his disease stabilized for 1 year without re-increase of tumor markers under continuous treatment with the combination therapy. CONCLUSIONS: High-dose TOR and DOC might be effective even beyond second-line chemotherapy and endocrine therapy for MBC to overcome potential multiple drug resistance and diminish inevitable side effects.     

Benefit of Sustained Virological Response to Combination Therapy on Graft Survival of Liver Transplanted Patients with Recurrent Chronic Hepatitis C

Recurrent hepatitis C infection is an important cause of progressive fibrosis, cirrhosis and graft loss after liver transplantation. Treatment for post-transplant recurrence results in sustained virological response (SVR) in up to 30% of cases. The aim of this study was to evaluate the impact of SVR on patients and graft survival. Thirty-four patients with an SVR to IFN-ribavirin were included. Forty-six nonresponders to the combination formed the control group. Follow-up data were recorded every 6 months and included HCV RNA, and the occurrence of clinical problems (cirrhosis, decompensation, hepatocellular carcinoma, death). A graft biopsy was performed every year. The mean follow-up duration was 52 months in responders and 57 months in nonresponders. Two patients died in each group of patients. Two patients with SVR developed late virological relapse. Fibrosis decreased in 38% of patients with SVR, remained stable in 44% and worsened in 18%. In contrast, fibrosis increased in the majority of nonresponder patients (74%, p<0.001). At the end of follow-up, no patient without cirrhosis at inclusion developed cirrhosis of the graft versus 9 among nonresponder patients (p=0.009). No difference in patient survival was observed in the two groups. In conclusion, this study shows that HCV eradication has a positive impact on graft survival.     

Keloid progression: a stiffness gap hypothesis

Keloids are fibroproliferative skin disorders characterised clinically by continuous horizontal progression and post‐surgical recurrence and histologically by the accumulation of collagen and fibroblast ingredients. Till now, their aetiology remains clear, which may cover genetic, environmental and metabolic factors. Evidence in the involvement of local mechanics (e.g. predilection site and typical shape) and the progress in mechanobiology have incubated our stiffness gap hypotheses in illustrating the chronic but constant development in keloid. We put forward that the enlarged gap between extracellular matrix (ECM) stiffness and cellular stiffness potentiates keloid progression. Matrix stiffness itself provides organisational guidance cues to regulate the mechanosensitive resident cells (e.g. proliferation, migration and apoptosis). During this dynamic process, the ECM stiffness and cell stiffness are not well balanced, and the continuously enlarged stiffness gap between them potentiates keloid progression. The cushion factors, such as prestress for cell stiffness and topology for ECM stiffness, serve as compensations, the decompensation of which aggravates keloid development. It can well explain the typical shape of keloids, their progression in a horizontal but not vertical direction and the post‐surgical recurrence, which were evidenced by our clinical cases. Such a stiffness gap hypothesis might be bridged to mechanotherapeutic approaches for keloid progression.     

瘢痕疙瘩的光电治疗

皮肤瘢痕疙瘩是以真皮内成纤维细胞过度增生、细胞外基质大量沉积、表皮结构异常为特点的皮肤纤维增生性疾病。其病因不清,临床上缺乏特异性的治疗手段。传统的治疗方法有外科手术、冷冻、压迫疗法、局部注射药物(激素、5-Fu等),但效果均不尽如人意。近年来,随着激光理论及技术的完善,光电治疗越来越多地应用于瘢痕的治疗,尤其是IPD/DPL、PDL等技术,可选择性作用于瘢痕疙瘩中毛细血管内的血红蛋白损伤血管内皮细胞,从而引起血管闭塞,起到使瘢痕组织"褪红"的效果,结合其他瘢痕治疗手段,可较好地抑制瘢痕疙瘩的生长。其他作用于瘢痕疙瘩基质的光电治疗手段,由于有刺激瘢痕疙瘩进一步增生的风险,临床上并不建议使用。     

Comparison of Morphine, Ketorolac, and Their Combination for Postoperative Pain: Results from a Large, Randomized, Double-blind Trial

Background: Meta-analyses report similar numbers needed to treat for nonsteroidal antiinflammatory drugs (NSAIDs) and opioids. Differences in baseline pain intensity among the studies from which these numbers needed to treat were derived may have confounded the results. NSAIDs have an opioid-sparing effect, but the importance of this effect is unclear. Therefore, the authors sought to compare the proportions of subjects who obtain pain relief with ketorolac versus morphine after surgery and to determine whether the opioid-sparing effect of an NSAID reduces the magnitude of opioid side effects.

Methods: The study was a double-blind, randomized controlled trial. The authors randomly assigned 1,003 adult patients to receive 30 mg ketorolac or 0.1 mg/kg morphine intravenously. They calculated the proportion of subjects who achieved at least 50% reduction in pain intensity 30 min after analgesic administration. Further, so long as pain intensity 30 min after analgesic administration was 5 or more out of 10, patients received 2.5 mg morphine every 10 min until pain intensity was 4 or less out of 10. The authors assessed the presence of opioid-related side effects.

Results: Five hundred patients received morphine and 503 received ketorolac. Fifty percent of patients in the morphine group achieved pain relief, compared with 31% in the ketorolac group (difference, 19%; 95% confidence interval, 13-25%). The ketorolac-morphine group required less morphine (difference, 6.5 mg; 95% confidence interval, -5.8 to -7.2) and had a lower incidence of side effects (difference, 11%; 95% confidence interval, 5-16%) than the morphine group.     

Keloid scar of the face

Although all the consultants agreed that this patient deserved to be treated, they disagreed as to the method. Dr. Wise suggested excision of the scar with postoperative irradiation. Dr. Thomas would excise the scar, inject the lesion with steroids intraoperatively and postoperatively, and apply a pressure dressing. Dr. Cook would not operate at all and favored intralesional injection of steroids. When used, Kenalog was the steroid preparation of choice. Dr. Wise would not use steroids in this situation because of the possible complications of skin atrophy, change in pigmentation, and telangiectasias. Dr. Thomas would avoid low-dose irradiation for fear of inducing a head and neck malignancy. Dr. Cook would avoid all surgical intervention, believing that it would only compound the present problem. All consultants agreed that the patient deserved close follow-up, and that he was at risk for similar scar formation in the future. They also pointed out the genetic predisposition for his offspring to have similar problems.