Laser treatment of recurrent herpes labialis: a literature review

Recurrent herpes labialis is a worldwide life-long oral health problem that remains unsolved. It affects approximately one third of the world population and causes frequent pain and discomfort episodes, as well as social restriction due to its compromise of esthetic features. In addition, the available antiviral drugs have not been successful in completely eliminating the virus and its recurrence. Currently, different kinds of laser treatment and different protocols have been proposed for the management of recurrent herpes labialis. Therefore, the aim of the present article was to review the literature regarding the effects of laser irradiation on recurrent herpes labialis and to identify the indications and most successful clinical protocols. The literature was searched with the aim of identifying the effects on healing time, pain relief, duration of viral shedding, viral inactivation, and interval of recurrence. According to the literature, none of the laser treatment modalities is able to completely eliminate the virus and its recurrence. However, laser phototherapy appears to strongly decrease pain and the interval of recurrences without causing any side effects. Photodynamic therapy can be helpful in reducing viral titer in the vesicle phase, and high-power lasers may be useful to drain vesicles. The main advantages of the laser treatment appear to be the absence of side effects and drug interactions, which are especially helpful for older and immunocompromised patients. Although these results indicate a potential beneficial use for lasers in the management of recurrent herpes labialis, they are based on limited published clinical trials and case reports. The literature still lacks double-blind controlled clinical trials verifying these effects and such trials should be the focus of future research.     

Radiofrequency-assisted liver resection

Radiofrequency (RF)-assisted thermal ablation has been used with increasing frequency for unresectable hepatic tumors. This new approach employs RF energy to coagulate the liver at the hepatic resection line after which hepatic resection is performed with the use of a common scalpel. This procedure was used in three patients with hepatocellular carcinoma and in five patients with colorectal metastasis to the liver. These eight patients underwent a total of two left bisegmentectomies, three segmentectomies, and seven wedge resections. Mean operative time was 220 minutes. A mean of 78 sessions of RF-assisted ablation were required for these resections. Mean blood loss was 46 ml; no device other than RF ablation was required to obtain hemostasis. None of the patients needed a blood transfusion. Preoperative hemoglobin was 12.8 gm/dl and postoperative hemoglobin was 11.3 gm/dl. There were no perioperative deaths. Postoperative complications occurred in two patients: a liver abscess in one and heart failure in the other. The mean hospital stay was 9.4 days. This new approach, integrated with other techniques, reduces blood loss and coagulates the margins of resection during liver surgery. This new technique has two limitations: (1) it cannot be applied near main portal pedicles, and (2) it requires a long operative time. The best indication for this technique is when segmentectomy is required in patients with cirrhosis. Its role in major hepatic resections has yet to be determined. Further progress in the development of thermal ablation techniques and experience gained during the learning curve should help reduce the operative time, thereby improving the safety and efficacy of this procedure. Presented at the Third International Meeting, "Hepatocellular Carcinoma: Eastern and Western Experience," Lodi, Italy, November 21–22, 2002.     

Does type 2 diabetes mellitus promote intervertebral disc degeneration?

Purpose

LDD is an important cause of low back pain. Many people believe there is an adverse influence of type 2 diabetes (T2D) on lumbar intervertebral disc degeneration (LDD). We examined a population sample for epidemiological evidence of association.

Methods

Twin volunteers from the TwinsUK cohort having spine magnetic resonance (MR) scans coded for LDD and information about T2D were investigated in two ways. First, as a population sample and second as a cotwin case control study in twin pairs discordant for T2D. Other risk factors for LDD considered were age, body-mass index (BMI), smoking, and alcohol.

Results

In 956 twin volunteers T2D had a prevalence of 6.6 %. LDD score was higher in T2D twins (14.9 vs 13.1 p = 0.04) but was not an independent risk factor if the influence of age and BMI were included in the model. Discordant twin analysis (n = 33 pairs) showed no significant difference in LDD between twins having T2D and their unaffected cotwins.

Conclusions

Twins having T2D did manifest higher LDD scores but the effect was abrogated once BMI was included in multivariable analysis, showing it is not an independent risk factor for LDD. The population study had 80 % power at 0.1 significance level to detect a difference of 1.8 in LDD score (range of 0–60), so if there is an effect of T2D on LDD, it is likely to be small.

     

Infrapopliteal Angioplasty for Limb Salvage in the Setting of Renal Failure: Do Results Justify Its Use?

Multiple reports advocate the use of infrapopliteal angioplasty for limb salvage; however, its utility in the setting of renal failure is unclear. We performed angioplasty, rather than bypass, for tibial stenoses or occlusions <3 cm on 90 limbs of 79 patients (64.4% male, mean age 67.2 years), all with ischemic ulcer. Seventy (77.8%) had diabetes mellitus and 16 (17.8%) had end-stage renal disease (ESRD). Mean follow-up was 14.3 months (range 0.3-45). Associated femoropopliteal revascularization was required in 28 (31.0%) limbs. Primary angiographic success was achieved in 83 (92.2%) limbs. Residual stenosis or thrombosis occurred in two and five limbs, respectively. Dissection occurred in six limbs, all successfully treated with stent placement. Ulcer healing occurred after initial angioplasty in 41 (55.4%) non-ESRD and four (25%) ESRD limbs. Subsequent revascularization procedures were required in 21 (23.3%) limbs, including six bypasses and 15 repeat angioplasties, of which three underwent subsequent bypasses. Major amputation was required in 11 (14.9%) non-ESRD and seven (43.7%) ESRD limbs. Limb salvage was 84.4% and 80.2% in those without and 52.5% and 52.5% in those with ESRD at 1 and 3 years, respectively (p = 0.01). Thirty-day mortality was 2.2%. Overall actuarial survival was 82.2% and 62.1% at 1 and 3 years, respectively, and did not differ significantly between patients with and without ESRD (p = 0.66). Infrapopliteal angioplasty is a safe technique with low procedural morbidity and mortality. However, the inferior wound-healing and limb-salvage rates observed in patients with renal failure bring to question the utility of infrapopliteal angioplasty in this population. Presented at the Fifteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, January 28-30, 2005.     

Surgical treatment of solitary adrenal metastasis from non-small cell lung cancer

BACKGROUND: Management of solitary adrenal metastasis from non-small cell lung cancer is still debated. Although classically considered incurable, various reports with small numbers of patients have shown that surgical treatment might improve long-term survival. The aim of this study was to review our experience and to identify factors that could affect survival. METHODS: From January 1989 through April 2003, 23 patients underwent complete resection of an isolated adrenal metastasis after surgical treatment of non-small cell lung cancer. There were 19 men and 4 women, with a mean age of 54 +/- 10 years. The diagnosis of adrenal metastasis was synchronous with the diagnosis of non-small cell lung cancer in 6 patients and metachronous in 17 patients. The median disease-free interval for patients with metachronous metastasis was 12.5 months (range, 4.5-60.1 months). RESULTS: The overall 5-year survival was 23.3%. Univariate and multivariate analysis demonstrated that a disease-free interval of greater than 6 months was an independent and significant predictor of increased survival in patients after adrenalectomy. All patients with a disease-free interval of less than 6 months died within 2 years of the operation. The 5-year survival was 38% after resection of an isolated adrenal metastasis that occurred more than 6 months after lung resection. Adjuvant therapy and pathologic staging of non-small cell lung cancer did not affect survival. CONCLUSIONS: Surgical resection of metachronous isolated adrenal metastasis with a disease-free interval of greater than 6 months can provide long-term survival in patients previously undergoing complete resection of the primary non-small cell lung cancer.     

Fatal neonatal nephrocutaneous syndrome in 18 Roma children with EGFR deficiency

Epidermal growth factor receptor (EGFR) is a transmembrane glycoprotein with tyrosine-kinase signaling activity, involved in many cellular functions including cell growth and differentiation. Germ line loss-of-function mutations in EGFR lead to a severe neonatal skin disorder (Online Mendelian Inheritance in Man #131550). We report 18 premature Roma children from 16 families with birthweights ranging 440–1470 g and multisystem diseases due to the homozygous mutation c.1283G˃A (p.Gly428Asp) in EGFR. They presented with thin, translucent, fragile skin (14/15), skin desquamation (10/17), ichthyosis (9/17), recurrent skin infections and sepsis (9/12), nephromegaly (10/16) and congenital heart defects (7/17). Their prognosis was poor, and all died before the age of 6 months except one 13-year-old boy with a severe skin disorder, dentinogenesis imperfecta, Fanconi-like syndrome and secondary hyperaldosteronism. Management of ion and water imbalances and extremely demanding skin care may improve the unfavorable outcome of such patients.     

Bilateral marginal keratitis associated with engraftment syndrome after hematopoietic stem cell transplantation

PURPOSE: To report the first case of bilateral marginal keratitis in the setting of engraftment syndrome in a patient who had undergone hematopoietic stem cell transplantation. METHODS: A 63-year-old man with a history of myelodysplastic syndrome presented with a 5-day history of red eyes. Two weeks before presentation, the patient had received a matched unrelated donor peripheral blood stem cell transplant and subsequently developed engraftment syndrome with a rapid white blood cell count recovery, noninfectious fever, skin rash, and shortness of breath. Ocular symptoms coincided with the timing of the white blood cell recovery. On examination, vision was 20/20 OU with +1 conjunctival injection with bilateral corneal subepithelial infiltrates in the periphery, particularly in areas of corneal pannus from previously existing contact lens-related neovascularization. There was no evidence of blepharitis, meibomian gland dysfunction, or uveitis. Ocular bacterial and viral cultures were negative, and a conjunctival biopsy was negative for viral inclusions or ocular graft-versus-host disease. RESULTS: The patient was initially treated with topical antibiotics for 2 days without any improvement and treated with topical corticosteroids 4 times daily. Examination 7 days after starting topical corticosteroids showed complete resolution of the marginal keratitis. CONCLUSIONS: Engraftment syndrome is notable for a rapid recovery of the white blood cell count after hematopoietic stem cell transplantation. Patients who present with presumed conjunctivitis in the setting of autologous and allogeneic stem cell transplantation should be evaluated for engraftment syndrome-related marginal keratitis.     

A novel in vivo rabbit model that mimics human dosing to determine the distribution of antibiotics in ocular tissues.

PURPOSE: The aim of this study was to establish a novel method to predict the human ocular penetration and distribution of topical antibiotics by using a controlled rabbit model that mimics the human eye with manual blinking and tear flow. METHODS: After anesthetizing the rabbits, a single dose of commercial antibiotic formulations was given with precision directly onto the cornea. This was followed by a 30-min controlled period applying manual blinking (4 blinks/min) and a supplementary tear flow (2 microL/min) that mimics the human eye. Tear samples were collected every 5 min and after euthanasia, conjunctival, aqueous humor, iris-ciliary body, and scleral samples were collected. The corneas were mounted in perfusion chambers to determine the level and continuing rate of release of the antibiotics, the levels of which were all determined using high-performance liquid chromatography analysis. RESULTS: U.S. formulations achieved conjunctival and corneal levels (mug/g) as follows: moxifloxacin, 6.6 +/- 0.3 and 50 +/- 5; tobramycin, 3.1 +/- 1.4 and 20 +/- 5; gentamicin, <2 and <2; levofloxacin, 1.5 +/- 0.3 and 19 +/- 2; gatifloxacin, 0.9 +/- 0.1 and 11 +/- 1; and trimethoprim, <0.1 and 2 +/- 1. Japan formulations achieved conjunctival and corneal levels as follows: levofloxacin 2.1 +/- 0.8 and 12 +/- 2; gatifloxacin, 2.2 +/- 0.9 and 7 +/- 1; ofloxacin, 1.6 +/- 0.5 and 7 +/- 1; and tosufloxacin, 0.7 +/- 0.1 and 1.5 +/- 0.3 (mean +/- standard error, n = 4). CONCLUSIONS: Moxifloxacin achieved the highest levels of antibiotic in ocular tissues. In the conjunctiva and cornea, the moxifloxacin level was 3-30 times the level of other fluoroquinolones, at least twice the level of the aminoglycosides, and 25 times the level of the antibacterial trimethoprim.