Orofacial granulomatosis of the lower lip and cheek: report of a case.

Orofacial granulomatosis (OFG) is a granulomatous disease of the orofacial region. This clinicopathological entity describes patients with oral lesions characterized by persistent and/or recurrent labial enlargement, ulcers, and a variety of other orofacial features, which on biopsy have lymphedema and noncaseating granulomas. The cause is idiopathic but appears to represent an abnormal immune reaction. This may be a manifestation of Crohn's disease (CD) since some patients with oral lesions develop typical bowel symptoms of CD in ensuing months to years; tooth-associated infections, sarcoidosis, food or contact allergies, and viruses have also been implicated in causing OFG. Clinical features of OFG are highly variable and sometimes so insidious that signs and symptoms are frequently not severe enough to cause alarm. The lips are most commonly involved and demonstrate a nontender, persistent swelling. Because of the relatively nonspecific clinical findings associated with granulomatous diseases, a microscopic diagnosis of granulomatous inflammation often presents a diagnostic dilemma for clinicians. We report a case of OFG of the lower lip and cheek and describe its management to add to the current body of literature on the subject.     

The prevalence of common CFTR mutations in Iranian infertile men with non-CAVD obstructive azoospermia by using ARMS PCR techniques

Purpose  

To evaluate five common cystic fibrosis trans-membrane conductance regulator (CFTR) mutations (ΔF508, G542X, R117H, W1282X and N1303K) in the Iranian infertile men with noncongenital absence of vas deferens (CAVD) obstructive azoospermia.     

Black veins: a case of minocycline‐induced pigmentation post‐sclerotherapy and a review of literature

Minocycline‐induced pigmentation (MIP) is an uncommon but well‐described adverse effect of oral minocycline treatment. MIP is clinically and histopathologically distinct from post‐sclerotherapy pigmentation. We report a case of a patient presenting with blackened skin overlying veins recently treated with endovenous laser and foam sclerotherapy. The patient was a 44‐year‐old male with systemic sclerosis who commenced minocycline for the treatment of rosacea 5 months prior. Histological examination of the discolored tissue and underlying vein revealed hemosiderin deposition in the dermis and pigmented macrophages within the sub‐endothelial layer of the vein wall with a staining pattern consistent with MIP. Venous tissue has not previously been reported in the literature as a target of minocycline pigmentation. Our patient preferred to control his rosacea by continuing to take minocycline. Follow‐up ultrasound examinations revealed the treated vessels to be fully occluded with no evidence of recanalization, residual flow or ongoing thrombophlebitis. Despite a good sclerotherapy outcome, the pigmentation did not subside over 2 years. This case demonstrates that oral minocycline may induce significant and potentially long‐term pigmentation in predisposed patients undergoing sclerotherapy.     

Antral-type mucosa in the gastric incisura, body, and fundus (antralization): a link between Helicobacter pylori infection and intestinal metaplasia?

OBJECTIVES: Helicobacter pylori is a carcinogen; gastric carcinoma involves a multistep process from chronic gastritis to atrophy, intestinal metaplasia, and dysplasia. The aims of this study were to determine the types of mucosa at different gastric sites in H. pylori-infected and uninfected patients, and whether the presence of antral-type mucosa in the incisura, body, and fundus is associated with gastric atrophy and intestinal metaplasia. METHODS: Two hundred and sixty-eight patients with dyspepsia were enrolled. Eight biopsies (i.e., antrum x3, body x2, fundus x2, and incisura x1) were obtained. One antral biopsy was used for the CLO-test. Three (each from the antrum, body, and fundus) were cultured. The remaining biopsies were examined histologically according to the updated Sydney System after staining with hematoxylin and eosin and Giemsa. A validated serological test was also applied. RESULTS: Overall, 113 (42%) patients were infected with H. pylori. At the incisura, antral-type mucosa was more prevalent in infected than in uninfected patients (84% vs. 18%; odds ratio [OR] = 23.9, 95% confidence interval [CI] 12.5-45.8; p<0.001). Atrophic gastritis and intestinal metaplasia at the incisura was present in 19.5% and 13.3%, respectively, of infected, and 4.5% and 3.2%, respectively, of uninfected patients (both p<0.01). Moreover, atrophic gastritis at the incisura was associated with the presence of antral-type mucosa at the site (termed antralization); the prevalence of atrophic gastritis was 19.5% (24/123) in the presence of antralization, whereas the rate was 2.1% (3/145) without antralization (OR = 11.4, 95% CI 3.4-39.2; p<0.001). Similarly, at the incisura, 16.3% (20/123) of "antralized" cases and 1.4% (2/145) of "unantralized" cases had intestinal metaplasia (OR = 13.8, 95% CI, 3.2-60.7; p<0.001). The association between antralization at gastric body and fundus also appeared to be associated with atrophic gastritis and intestinal metaplasia at these sites. CONCLUSIONS: Atrophic gastritis and intestinal metaplasia occurs predominantly at the gastric antrum and incisura with H. pylori infection. Antralization of the gastric incisura is a common event in H. pylori-infected patients, and appears to be associated with an increased risk of atrophic gastritis and intestinal metaplasia.     

Glycemic Control and Burnt‐Out Diabetes in ESRD

Treatment of early diabetes mellitus, the most common cause of chronic kidney disease (CKD), may prevent or slow the progression of diabetic nephropathy and lower mortality and the incidence of cardiovascular disease in the general diabetic population and in patients with early stages of CKD. It is unclear whether glycemic control in patients with advanced CKD, including those with end‐stage renal disease (ESRD) who undergo maintenance dialysis treatment is beneficial. Aside from the uncertain benefits of treatment in ESRD, hypoglycemic interventions in this population are also complicated by the complex changes in glucose homeostasis related to decreased kidney function and to dialytic therapies, occasionally leading to spontaneous resolution of hyperglycemia and normalization of hemoglobin A1c levels, a condition which might be termed “burnt‐out diabetes.” Further difficulties in ESRD are posed by the complicated pharmacokinetics of antidiabetic medications and the serious flaws in our available diagnostic tools used for monitoring long‐term glycemic control. We review the physiology and pathophysiology of glucose homeostasis in advanced CKD and ESRD, the available antidiabetic medications and their specifics related to kidney function, and the diagnostic tools used to monitor the severity of hyperglycemia and the therapeutic effects of available treatments, along with their deficiencies in ESRD. We also review the concept of burnt‐out diabetes and summarize the findings of studies that examined outcomes related to glycemic control in diabetic ESRD patients, and emphasize areas in need of further research.     

Bilateral tunneled supraclavicular island flaps for simultaneous reconstruction of massive facial defect and intraoral lining

Reconstructive procedures in the head and neck region use a wide range of flaps for defect closure. The methods range from local, mostly myocutaneous flaps and skin grafts to free microsurgical flaps. To ensure a satisfactory functional and aesthetic result, good texture and color of the flap are always essential. Moreover, the donor-site defect needs to be reduced, with no resulting functional or aesthetic impairment. The supraclavicular island flap has been used successfully for difficult facial reconstruction cases, providing acceptable results without using microsurgical techniques. As a complementary study to the publication by Heitland and Pallua (Plast Reconstr Surg 2005;115:1591), we report our preliminary clinical experience with bilateral tunneled supraclavicular island flaps for simultaneous reconstruction of massive facial defect and intraoral lining in massively progressed invasive squamous cell carcinoma of the lower lip with severe intraoral extension. This thin flap is easy and quick to harvest, has a reliable pedicle, and has minimal donor-site morbidity. It is now the authors' flap of choice for many common head and neck reconstructive problems.     

Experience with the prefabricated free fibula flap for reconstruction of maxillary and mandibular defects.

PURPOSE: We report our 11-year experience with a new technique to prefabricate the osteocutaneous free fibula flap to reconstruct defects of the maxilla and mandible not amenable to conventional methods of treatment. MATERIAL AND METHODS: We treated 11 patients aged 17 to 47 years with jaw defects using prefabricated free fibula grafts from 1994 to 2005. We prepared the fibula on the leg with a 6- to 8-mm muscle cuff; next we transferred the bone flap to the surface of the leg without severing the pedicle, and then covered the muscle almost circumferentially by partial thickness skin graft. The bone flap was left in place with its pedicle intact for 2 to 3 months, after which the skin graft had taken and the flap was free of inflammation. The fibula flap was then transferred to the face, fixed in place with plates, and microvascular anastomosis was performed. Implant placement was completed 4 to 6 months after transfer of the flap to the oral cavity. RESULTS: Graft take was unremarkable in all cases. There were no cases of infection and only minor complications. Edema of the flap may be encountered, which subsides with time. If the mandible is not edentulous the mandibular teeth may bite into the flap, but these wounds heal by the time the patient is ready for implant insertion (3 to 6 months). Implants placed in the fibula were successful during the follow-up period (2 to 13 years). CONCLUSION: The prefabricated fibula with a "banking time" on the leg for flap maturation seems to be a better choice compared with other methods of using the fibula for reconstruction and has passed the test of time. We hereby report this new technique to add to the armamentarium of jaw reconstruction surgery.