Daylight photodynamic therapy with MAL cream for large‐scale photodamaged skin based on the concept of ‘actinic field damage’: recommendations of an international expert group

Conventional PDT (c‐PDT) is a widely used and approved non‐invasive treatment for actinic keratosis (AK). Recent clinical, histological and immunohistochemical observations have shown that c‐PDT with methyl aminolevulinate (MAL) may also partially reverse the signs of photodamage. However, pain and the need for special light source equipment are limiting factors for its use, especially in the treatment of large areas. More recently, daylight PDT (DL‐PDT) has been shown to be similar to c‐PDT in the treatment of AK, nearly painless and more convenient to perform. To establish consensus on recommendations for the use of MAL DL‐PDT in patients with large‐scale photodamaged skin. The expert group was comprised of eight dermatologists. Consensus was developed based on the personal experience of the experts in c‐PDT and DL‐PDT, and results of an extensive literature review. MAL DL‐PDT for large areas of photodamaged skin was evaluated and recommendations based on broad clinical experience were provided. As supported by evidence‐based data from multicentre studies conducted in Australia and Europe, the authors defined the concept of ‘actinic field damage’ which refers to photodamage associated with actinic epidermal dysplasia, and provide comprehensive guidelines for the optimal use of DL‐PDT in the treatment of actinic field damage. The authors concluded that MAL DL‐PDT has a similar efficacy to c‐PDT at 3‐month (lesion complete response rate of 89% vs. 93% in the Australian study and 70% vs. 74% in the European study (95% C.I. = [?6.8;?0.3] and [?9.5;2.4] respectively) and 6‐month follow‐ups (97% maintenance of complete lesion response) in the treatment of AKs. The authors agree that DL‐PDT is not only efficacious but also nearly pain‐free and easy to perform, and therefore results in high patient acceptance especially for the treatment of areas of actinic field damage.     

Treating facial overfilled syndrome with impaired facial expression—Presenting clinical experience with ultrasound imaging

Background

Facial overfilled syndrome is an adverse event following minimally invasive soft tissue filler injections. It presents in most cases as excess midfacial volume and/or as unnatural smile which is difficult to detect due to the absence of standardized evaluation methods.

Objective

To showcase how to identify, evaluate, and treat facial overfilled syndrome by utilizing facial ultrasound and simultaneous hyaluronidase injections.

Methods

Twenty-eight consecutive patients (26 females, 2 males) were enrolled in this study in which facial ultrasound was performed to evaluate the location previously implanted filler material. The position of the oral commissure was objectively measured in relation to bony landmarks, and the severity of lateral canthal lines was assessed by independent and blinded raters.

Results

The material was identified in 35.7% inside the subdermal fatty layer, in 28.6% inside the deep supra-periosteal fatty layer, in 10.7% inside the fibrous layer deep to the subdermal fatty layer, whereas in 25.0%, the product was not possible to locate clearly inside one specific layer. On average, 81.6 I.U. [range: 75–150] of hyaluronidase were injected. Lateral canthal line severity was before the treatment 2.28 (1.4) and was after the hyaluronidase treatment 2.02 (1.3) with p = 0.578. The position of the oral commissure increased by 0.60 cm in vertical and by 0.30 cm in horizontal directions (both p < 0.001).

Conclusion

Facial overfilled syndrome following aesthetic soft tissue filler injections can present as excess midfacial volume but also as unnatural smile. Targeted hyaluronidase injections into the culprit pockets inside the midfacial soft tissues have shown to re-establish a natural smile, to reduce excess midfacial volume, and to decrease lateral canthal line severity.     

Systemic coronary surgery in the beating heart. Experience in 250 cases

OBJECT: To report our recent experience with off-pump coronary artery revascularization in multi-vessel disease. METHODS: Between October 1996 and August 1998, 250 off-pump (OP) procedures were completed at the Montreal Heart Institute, representing more than 90% of all procedures done during the same time frame (97% for 1998). These patients have been compared to 1870 patients operated upon under cardiopulmonary bypass during the years 1995-1996 (CPB). RESULTS: Mean age, sexe distribution, and preoperative risk factors were comparable for both groups. On average 2.89 +/- 0.8 and 2.84 +/- 0.6 grafts/patient were completed in OP and CPB groups respectively. A majority (70%) of patients had either a triple or quadruple bypass. Coronary anastomoses were achieved with myocardial mechanical stabilization and heart "verticalization". Ischemic time was shorter in the OP group (29.8 +/- 0.9 vs 45 +/- 0.4 min, p < 0.05). Similarly, need for transfusion was significantly less (OP: 34 vs CPB: 66%, p < 0.005). Use of postoperative intra-aortic counterpulsation as well as the raise of CK-MB were lesser in the OP group. Operative mortality (OP: 1.6%, vs CPB: 2%, p = ns) and perioperative myocardial infarction rate (OP: 3.6% vs CPB: 4.2) were comparable for both groups. CONCLUSION: Off-pump complete coronary artery revascularization is an acceptable alternative to conventional surgery in a majority of patients with good results given progressive experience, rigorous technique, and adequate coronary artery stabilization.     

Continuous facial nerve monitoring during pleomorphic adenoma recurrence surgery

OBJECTIVES: Surgery of recurrent pleomorphic adenoma (RPA) is known to lead to a high facial nerve complication rate. The efficacy of the continuous facial nerve monitoring (CFNM) technique remains to be proven in RPA surgery. The goal was thus to evaluate facial nerve palsy rates and the recovery period after parotidectomy for RPA using CFNM by way of continuous electromyography and to compare these rates and the operation time with those of patients who had undergone surgery without facial nerve monitoring. DESIGN: Cohort study. PATIENTS: Forty-seven patients were referred for RPA (1981-2003). Among them, 32 (18 unmonitored and 14 monitored) patients displayed no preoperative facial palsy, and histologic analyses revealed evidence of recurrence. The operation time and the extent and duration of postoperative facial nerve palsy were examined in both groups (monitored vs. unmonitored). Both groups had a similar clinical appearance distribution. RESULTS: Facial nerve paralysis was estimated using the House-Brackmann grading scale. CFNM reduced the intensity of facial nerve paralysis independently of the kind of surgery performed. The complete deficit rates were 0% for the monitored group and 5.6% for the unmonitored group. Postoperative facial nerve paralysis was significantly lower (P = .01) in the monitored group than in the unmonitored group. CFNM improved the duration of facial paralysis (P = .001) in the monitored group. The operation time was significantly lower in the monitored group than in the unmonitored group (P = .001). CONCLUSIONS: Routine use of CFNM during RPA surgery improves the surgical outcome. The facial nerve deficit can be reduced, and the recovery of facial nerve function is faster.     

Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using the second- and current third-generation self-expanding CoreValve prosthesis: device success and 30-day clinical outcome.

OBJECTIVES: We sought to determine both the procedural performance and safety of percutaneous implantation of the second (21-French [F])- and third (18-F)-generation CoreValve aortic valve prosthesis (CoreValve Inc., Irvine, California). BACKGROUND: Percutaneous aortic valve replacement represents an emerging alternative therapy for high-risk and inoperable patients with severe symptomatic aortic valve stenosis. METHODS: Patients with: 1) symptomatic, severe aortic valve stenosis (area <1 cm2); 2) age > or =80 years with a logistic EuroSCORE > or =20% (21-F group) or age > or =75 years with a logistic EuroSCORE > or =15% (18-F group); or 3) age > or =65 years plus additional prespecified risk factors were included. Introduction of the 18-F device enabled the transition from a multidisciplinary approach involving general anesthesia, surgical cut-down, and cardiopulmonary bypass to a truly percutaneous approach under local anesthesia without hemodynamic support. RESULTS: A total of 86 patients (21-F, n = 50; 18-F, n = 36) with a mean valve area of 0.66 +/- 0.19 cm2 (21-F) and 0.54 +/- 0.15 cm2 (18-F), a mean age of 81.3 +/- 5.2 years (21-F) and 83.4 +/- 6.7 years (18-F), and a mean logistic EuroSCORE of 23.4 +/- 13.5% (21-F) and 19.1 +/- 11.1% (18-F) were recruited. Acute device success was 88%. Successful device implantation resulted in a marked reduction of aortic transvalvular gradients (mean pre 43.7 mm Hg vs. post 9.0 mm Hg, p < 0.001) with aortic regurgitation grade remaining unchanged. Acute procedural success rate was 74% (21-F: 78%; 18-F: 69%). Procedural mortality was 6%. Overall 30-day mortality rate was 12%; the combined rate of death, stroke, and myocardial infarction was 22%. CONCLUSIONS: Treatment of severe aortic valve stenosis in high-risk patients with percutaneous implantation of the CoreValve prosthesis is feasible and associated with a lower mortality rate than predicted by risk algorithms.     

Consequences of adenosine deaminase deficiency on thymocyte metabolism

Using 2′-deoxycoformycin inhibition of adenosine deaminase as a model of adenosine deaminase deficiency, the effects of 10 μM 2′-deoxyadenosine (dAdo) on the metabolism of concanavalin A (Con A)-stimulated rat thymocytes were studied. When dAdo and Con A were added simultaneously, a strong inhibition of the incorporation of [³H]thymidine (84%); [³H]uridine (98%) and L-[³H] leucine (46%) in the acid-insoluble fraction, and of [¹⁴C]formate (78%) and H¹⁴CO₃^? (43%) uptake is observed after 48 h of incubation. When dAdo is added after 12 h of Con A stimulation, no such inhibition is observed, but when added after 24 h of stimulation, there is an enhancement of blastogenesis as measured by nucleic acid, protein, and purine and pyrimidine base synthesis. More detailed studies of thymocytes stimulated by Con A for 0–72 h, followed by short-term incubation periods with dAdo (1–5 h), revealed that thymocyte metabolism becomes progressively less sensitive to dAdo-mediated inhibition during the course of blastogenesis.     

Histological features and HLA class II alleles in hepatitis C virus chronically infected patients with persistently normal alanine aminotransferase levels

OBJECTIVE: A significant proportion of individuals with chronic hepatitis C virus (HCV) infection have persistently normal alanine aminotransferase (ALT) levels. Although data are controversial, such patients usually have weaker histological damage and a lower progression rate of fibrosis. The aims of this study were: (1) to compare demographic, virological, and histological parameters of HCV patients with normal ALT values with those of HCV patients with elevated ALT levels; and (2) to determine whether HLA class II alleles contribute to the persistence of normal ALT levels in HCV patients. PATIENTS AND METHODS: Eighty three patients with chronic HCV infection and persistently normal ALT values (group 1) and 233 patients with chronic HCV infection and elevated ALT levels (group 2) were studied. Histological features were expressed using Knodell and Metavir scores. HLA DRB1* and DQB1* genotyping was performed using hybridisation with sequence specific oligonucleotides after genomic amplification. The kappa2 and Fisher's exact tests were used to compare discrete variables and phenotype frequencies between the two groups, and Wilcoxon's test was used for continuous variables. A multivariate logistic regression model was used to determine which variables predicted normal ALT values. RESULTS: ALT levels were correlated with the severity of liver damage. In group 1, 93% of patients had an F0 or F1 Metavir index of fibrosis compared with 47% of patients in group 2 (p<0.001). A longer duration of infection (p<0.001) and increased DRB1*11 phenotype frequency (pc=0.03) were observed among patients with normal ALT. The two groups did not differ with regard to the mode of contamination or viral genotype. After logistic regression, young age (p=0.0008), female sex (p=0.01), long duration of infection (p=0.0001), and HLA DRB1*11 (p=0.050) were more strongly associated with persistence of normal ALT. CONCLUSIONS: Our study confirms that patients with chronic hepatitis C and normal ALT levels have less severe liver disease than those with elevated ALT levels. This particular biochemical outcome may be explained, at least in part, by host immunogenetic factors such as the presence of HLA-DRB1*11.     

Monitoring of peak expiratory flow rates in subjects with mild airway hyperexcitability

Twenty-seven subjects with mild symptoms of bronchial hyperexcitability (cough, dyspnea, wheezing) and low to moderate degree of airway response to histamine monitored their peak expiratory flow rates (PEFR) for a mean +/- SD of 14.4 +/- 4.0 days. This assessment was performed without the use of any medication in 15 subjects, and before and after inhalation of salbutamol in 12 others. 100% and 52% of individuals, respectively, showed baseline FEV1 and maximum mid-expiratory flow rates greater than 80% of predicted. The improvement in FEV1 after salbutamol was less than 20% in every subject and from 10 to 20% in 15%. The mean daily percentage changes in PEFR were greater than the ones observed in normal individuals in only 21% and 50% of the subjects on no medication and on salbutamol, respectively. Diurnal changes in PEFR were significantly negatively correlated with the response to histamine (r = -0.51; p less than 0.01) and baseline FEV1 (r = -0.49; p less than 0.02). We conclude that there are minor fluctuations of PEFR in subjects with mild symptoms and low degree of airway excitability.