Marjolin ulcer: an overlooked entity

Marjolin ulcer is a well-defined, but uncommon malignant ulcer that occurs in chronic wounds and cutaneous scars. Jean-Nicolas Marjolin was credited with describing this phenomenon in 1828. This entity is frequently overlooked and therefore inadequately treated leading to a poor prognosis. The malignant transformation of an ulcer is most commonly associated with burn scars, but has been reported in many other types of chronic, non healing wounds such as traumatic wounds, venous stasis and chronic pressure ulcers, fistulas, lacerations and leprosy ulcers. Development of malignancy tends to be slow with an average time of approximately 25 years. Various theories concerning pathogenesis of Marjolin ulcer have been proposed. Well-differentiated squamous cell carcinoma (SCC) is the most common histological type of Marjolin ulcer. Biopsy with histopathologic interpretation remains the gold standard for the diagnosis, with radical surgical excision being the treatment of choice. A high index of suspicion should be held by any health care provider when evaluating a chronic, non healing wound. This is a case report of a Marjolin ulcer arising on the left buttock of a patient with a long-standing history of a traumatic wound.     

Coronary bifurcation lesions treated with simple approach (from the Cordoba & Las Palmas [CORPAL] Kiss Trial)

The present report compared the incidence of 1-year clinical events in patients with bifurcation lesions that had been treated with a simple approach who were randomized to either a simultaneous final kissing balloon (KB) or an isolated side-branch (SB) balloon post-dilation. From February 2007 to December 2008, 293 patients with all types of Medina bifurcation lesions were enrolled in a prospective study. All patients underwent implantation of a sirolimus- or everolimus-eluting stent across the bifurcation and provisional SB stenting. Patients with no SB ostial compromise or those needing a second stent were excluded from the present study (n = 49). The eligible patients were randomly assigned to treatment with final KB inflation (n = 124, KB group) or isolated balloon after dilation (n = 120, non-KB group). No significant differences were found between the patients from the KB and non-KB groups in terms of age, risk factors, clinical status, or location of the bifurcation lesions. The angiographic data and immediate results were also similar in both groups. Four patients experienced a non-Q-wave acute myocardial infarction in the hospital: three (2%) from the KB group and one (1%) from the non-KB group. Two in-hospital deaths occurred in the non-KB group. Target lesion revascularization was required in 7 patients (3%): 5 from the KB group and 2 from the non-KB group. Late mortality occurred in 3 patients from the KB group and 2 patients from the non-KB group. The incidence of major events at 1 year (death, target lesion revascularization, or acute myocardial infarction) was similar in both groups: 11 (9%) from the KB group and 7 (6%) from the non-KB group (p = NS). In conclusion, no differences in the clinical outcome at 1 year of follow-up were observed between the patients with bifurcation lesions treated with a simple approach and either a simultaneous final KB or an isolated SB balloon post-dilation.     

The diagnostic role of gated myocardial perfusion imaging and radionuclide ventriculography in severe congenital heart disease

Several techniques have been applied for the assessment of severe congenital heart diseases (SCHD) including echocardiography, cardiac catheterization with angiocardiography, and more recently, cardiovascular multi detector tomography and magnetic resonance imaging (MRI). The value of gated single photon emission tomography (GSPET) myocardial perfusion imaging (MPI) and radionuclide ventriculography (RNV) for evaluating myocardial ischemia, tissue viability, and left ventricular function in SCHD is less apparent. The risk of radiation exposure is greatest in the youngest patients. Both, GSPET MPI and RNV seem to be underutilized in pediatric clinical practice due to increased radiation exposure. We have reviewed basic and specific technical and diagnostic aspects, as well as specific clinical indications of GSPET MPI and RNV in children with SCHD in comparison with other cardiology methods. Some of our own tests are also presented where they apply. In conclusion, GSPET MPI and RNV can provide clinical relevant information of functional significance of SCHD in pediatric patients especially when the other cardiology methods are indeterminate. With regard to radiation exposure appropriate patient selection and recommendations for reduction of radiation exposure are of great importance.     

Intraperitoneal instillation of polihexanide produces hypotension and vasodilation: in vivo and in vitro study in rats

Background and aims Treatment of peritonitis may include abdominal lavage with a local disinfectant polihexanide, available as 0.04% solution, which is often accompanied by hypotension.Methods We examined the effects of peritoneal installation of polihexanide or NaCl 0.9% (10 ml each, for 10 min; polihexanide n=5, NaCl n=5) on mean arterial pressure in healthy rats and, using intravital microscopy, measured in seven other animals the diameter of terminal ileum submucosal arterioles and venules before and after local superfusion with polihexanide. Furthermore, in an in vitro isometric preparation of rat thoracic aortal rings, with and without endothelium, we tested the effects of cumulative concentrations of polihexanide on vascular basic tension and on tension elicited by phenylephrine and KCl.Results It was found that polihexanide peritoneal instillation produced a decrease in mean arterial pressure, while superfusion with polihexanide caused local vasodilation of intestinal wall blood vessels. In vitro, polihexanide produced endothelium-dependent relaxation in the preparations pre-contracted with phenylephrine (EC₅₀, polihexanide 0.04% solution 2.53±0.16 vs. 1.36±0.16, n=4, P<0.05; polihexanide 4.02±0.12 vs. 3.21±0.10, n=12, P<0.001;+ vs. − endothelium, respectively; −log g%) which (in aortae +endothelium) could be attenuated by either N(G)-nitro-l-arginine methyl ester, a nitric oxide generation inhibitor, or 1H-(1,2,4)oxodiazolo-(4,3-a)quinoxalin-1-one, an inhibitor of guanylyl cyclase. The relaxing effect of polihexanide (aortae -endothelium) was not affected by K⁺-channel blocking agents charybdotoxin, tetraethylammoniumchloride, glibenclamide or 4-aminopyridine, while polihexanide had no effects on 40-mM KCl contractions.Conclusion This implies that polihexanide may promote nitric oxide liberation, potassium channel activation and vasodilation that may result in hypotension.H. Frieling and M. Gründling have contributed equally to the present work     

A New Era in Clinical Genetic Testing for Hypertrophic Cardiomyopathy

Building on seminal studies of the last 20 years, genetic testing for hypertrophic cardiomyopathy (HCM) has become a clinical reality in the form of targeted exonic sequencing of known disease-causing genes. This has been driven primarily by the decreasing cost of sequencing, but the high profile of genome-wide association studies, the launch of direct-to-consumer genetic testing, and new legislative protection have also played important roles. In the clinical management of hypertrophic cardiomyopathy, genetic testing is primarily used for family screening. An increasing role is recognized, however, in diagnostic settings: in the differential diagnosis of HCM; in the differentiation of HCM from hypertensive or athlete’s heart; and more rarely in preimplantation genetic diagnosis. Aside from diagnostic clarification and family screening, use of the genetic test for guiding therapy remains controversial, with data currently too limited to derive a reliable mutation risk prediction from within the phenotypic noise of different modifying genomes. Meanwhile, the power of genetic testing derives from the confidence with which a mutation can be called present or absent in a given individual. This confidence contrasts with our more limited ability to judge the significance of mutations for which co-segregation has not been demonstrated. These variants of “unknown” significance represent the greatest challenge to the wider adoption of genetic testing in HCM. Looking forward, next-generation sequencing technologies promise to revolutionize the current approach as whole genome sequencing will soon be available for the cost of today’s targeted panel. In summary, our future will be characterized not by lack of genetic information but by our ability to effectively parse it.     

Association of serum bilirubin and uric acid levels changes during neuroinflammation in patients with initial and relapsed demyelination attacks

In order to examine the endogenous antioxidants values in the earliest phase of demyelination, we have determined bilirubin and uric acid (UA) serum values in the patients with clinically isolated syndrome (CIS) and relapsing remitting multiple sclerosis (RRMS), regarding their clinical disability, measured by Extended Disability Status Scale (EDSS), Magnetic Resonance Imaging (MRI), disease duration, gender and other parameters. The bilirubin and UA levels were lower in CIS and RRMS patients than in control group, whether male or female (p?<?0.05). The bilirubin and UA levels were decreased in RRMS compared to CIS patients (p?<?0.05). Regarding EDSS, MRI and disease duration, obtained values of bilirubin and UA were higher in both study groups in patients with lower EDSS, lower MRI lesion number and shorter disease duration (p?<?0.05). The greatest significance in decreased bilirubin and UA levels was observed in female compared to male patients, in both study groups (p?<?0.05). The results suggest negative linear correlation between bilirubin and UA levels and disease duration, EDSS and MRI in CIS (p?<?0.01), with the same correlation between bilirubin and UA levels and disease duration in RRMS patients (p?<?0.01). There was also significant correlation between bilirubin level and MRI findings and UA levels and EDSS in RRMS patients (p?<?0.01). The obtained results point to the importance of endogenous antioxidants in the outbreak and course of neuroinflammation. This could be favorable for the new pathogenetically conditioned neuroinflammatory therapy concepts which do not initially rely only on immunomodulatory, but also on the antioxidative effects.