Treatment options for hypercalcemia after cosmetic oil injections: Lessons from human tissue cultures and a pilot intervention study.

OBJECTIVE: Granuloma formation following self-administered cosmetic oil injections can lead to severe hypercalcemia and renal calcifications due to extra-renal vitamin D activation. This translational study aims to identify Prednisolone sparing therapeutics for hypercalcemia after development of granulomatous disease secondary to paraffin oil injections. MATERIALS AND METHODS: Granuloma tissue isolated from five men were cultured ex vivo and treated with selected drugs to block generation of activated vitamin D (1,25(OH)2D3). In a retrospective study, we included data before and during different treatments of 21 men with paraffin oil induced granulomatous hypercalcemia (46 treatment courses) where serum calcium, parathyroid hormone, vitamin D metabolites, creatinine and inflammatory markers were measured. RESULTS: Addition of Ketoconazole or Ciclosporin to granuloma tissue ex vivo culture, significantly suppressed production of 1,25(OH)2D3 after 48 h (both p < 0.05). Prednisolone was the first treatment option in most men and lowered serum levels of ionized calcium after 1, 2, 3 and 6 months compared with baseline (p < 0.05). Ketoconazole or Hydroxychloroquine had no significant effect on serum calcium levels and were unable to reduce the concomitant daily Prednisolone doses (p > 0.05). Azathioprine did not reduce calcium levels. However, addition of Tacrolimus to Prednisolone treatment enabled a reduction in Prednisolone dose after 3 months (p = 0.014), but with no additional effect on calcium homeostasis. CONCLUSION: This study verifies that Prednisolone is an effective treatment and suggests that calcineurin inhibitors may be used as Prednisolone sparing treatment for paraffin oil-induced granulomatous hypercalcemia. Randomized clinical trials are needed to determine clinical efficacy.

Extramammary Paget's Disease and Melanoma: 2 Cases of Double Cancers.

Extramammary Paget's disease (EMPD) is a rare intraepidermal neoplastic disease. There is a well-known relationship between EMPD and underlying malignancy. However, only a few cases of EMPD and cutaneous melanoma have been reported previously. In this case report we present 2 cases of such double cancers: one as a collision tumor, the other at separate sites. We discuss the pathogenesis, treatment, and importance of a thorough clinical and radiological examination and review the literature.

Fluorescent Analogues of Human α-Calcitonin Gene-Related Peptide with Potent Vasodilator Activity.

: Human α-calcitonin gene-related peptide (h-α-CGRP) is a highly potent vasodilator peptide that belongs to the family of calcitonin peptides. There are two forms of CGRP receptors in humans and rodents: α-CGRP receptor predominately found in the cardiovascular system and ß-CGRP receptor predominating in the gastrointestinal tract. The CGRP receptors are primarily localized to C and Aδ sensory fibers, where they are involved in nociceptive transmission and migraine pathophysiology. These fibers are found both peripherally and centrally, with extensive perivascular location. The CGRP receptors belong to the class B G-protein-coupled receptors, and they are primarily associated to signaling via Gα proteins. The objectives of the present work were: (i) synthesis of three single-labelled fluorescent analogues of h-α-CGRP by 9-fluorenylmethyloxycarbonyl (Fmoc)-based solid-phase peptide synthesis, and (ii) testing of their biological activity in isolated human, mouse, and rat arteries by using a small-vessel myograph setup. The three analogues were labelled with 5(6)-carboxyfluorescein via the spacer 6-aminohexanoic acid at the chain of Lys24 or Lys35. Circular dichroism (CD) experiments were performed to obtain information on the secondary structure of these fluorescently labelled peptides. The CD spectra indicated that the folding of all three analogues was similar to that of native α-CGRP. The three fluorescent analogues of α-CGRP were successfully prepared with a purity of >95%. In comparison to α-CGRP, the three analogues exhibited similar efficacy, but different potency in producing a vasodilator effect. The analogue labelled at the N-terminus proved to be the most readily synthesized, but it was found to possess the lowest vasodilator potency. The analogues labelled at Lys35 or Lys24 exhibited an acceptable reduction in potency (i.e., 3-5 times and 5-10 times less potent, respectively), and thus they have potential for use in further investigations of receptor internalization and neuronal reuptake.

The Danish Scale for visual rating of massive weight loss body contours. Conceptualization and construct.

The 'Danish Scale' (DS) is a visual rating scale of massive weight loss body contour deformities and excessive skin in female MWL-patients with current BMI < 30 kg/m2 and massive weight loss defined as BMI loss (delta-BMI) > 15 kg/m2, regardless of weight loss method. The scope of the scale is to simplify the reporting of objective findings by a three-step grading of minor, moderate and severe body contour changes in six different body regions: breasts, abdomen, upper back, buttocks, arms and legs. The DS is presented with descriptions of the conceptualization and construct of the scale. It provides a new visual reference tool for indications and preoperative planning in MWL body contouring, that is specific for the post-MWL BMI-range between 21 and 30 kg/m2 and, at the same time, simpler than previous scales. The scale combines evaluations of different and adjacent body regions in a simple manner and presents modern cut-off points for health insurance reimbursement for MWL body contouring as offered in the Danish public health care system. The DS was developed by repeat expert discussions until final nationwide consensus was reached and can act as an adjunct to the written guidelines by the National Board of Health in Denmark.

Expression of endothelin type B receptors (EDNRB) on smooth muscle cells is controlled by MKL2, ternary complex factors, and actin dynamics.

The endothelin type B receptor (ETB or EDNRB) is highly plastic and is upregulated in smooth muscle cells (SMCs) by arterial injury and following organ culture in vitro. We hypothesized that this transcriptional plasticity may arise, in part, because EDNRB is controlled by a balance of transcriptional inputs from myocardin-related transcription factors (MRTFs) and ternary complex factors (TCFs). We found significant positive correlations between the TCFs ELK3 and FLI1 versus EDNRB in human arteries. The MRTF MKL2 also correlated with EDNRB. Overexpression of ELK3, FLI1, and MKL2 in human coronary artery SMCs promoted expression of EDNRB, and the effect of MKL2 was antagonized by myocardin (MYOCD), which also correlated negatively with EDNRB at the tissue level. Silencing of MKL2 reduced basal EDNRB expression, but depolymerization of actin using latrunculin B (LatB) or overexpression of constitutively active cofilin, as well as treatment with the Rho-associated kinase (ROCK) inhibitor Y27632, increased EDNRB in a MEK/ERK-dependent fashion. Transcript-specific primers indicated that the second EDNRB transcript (EDNRB_2) was targeted, but this promoter was largely unresponsive to LatB and was inhibited rather than stimulated by MKL2 and FLI1, suggesting distant control elements or an indirect effect. LatB also reduced expression of endothelin-1, but supplementation experiments argued that this was not the cause of EDNRB induction. EDNRB finally changed in parallel with ELK3 and FLI1 in rat and human carotid artery lesions. These studies implicate the actin cytoskeleton and ELK3, FLI1, and MKL2 in the transcriptional control of EDNRB and increase our understanding of the plasticity of this receptor.

Vasomotor dysfunction in human subcutaneous arteries exposed ex vivo to food-grade titanium dioxide.

Animal studies have shown that titanium dioxide (TiO2) exposure affects arterial vasomotor function, whereas little is known about the effects in arteries from humans. This study investigated vasomotor responses after direct exposure of human subcutaneous arteries to food-grade TiO2 (E171) (14 or 140 µg/ml) for 30 min and 18 h. Vasomotor responses to bradykinin, 5-hydroxytryptamine (5-HT), sarafotoxin 6c (S6c) and nitroglycerin were recorded in wire-myographs. Vasoconstrictor responses to 5-HT were increased in arteries exposed to E171 for 18 h (P < 0.05). Furthermore, an increase in S6c responses was seen in low concentration E171 exposed arteries (30 min exposure; P < 0.05). The vasorelaxation response to nitroglycerin was increased in low concentration E171 exposed arteries (30 min exposure; P < 0.05). Vasorelaxation responses to bradykinin were unaffected after treatment with E171. There was no difference in gene expression levels of intercellular cell adhesion molecule 1, vascular cell adhesion molecule 1, 5-hydroxytryptamine receptor 1B, 5-hydroxytryptamine receptor 2A, endothelin receptor A and endothelin receptor B in E171 exposed arteries after exposure to TiO2 for 30 min or 18 h. In conclusion, this study shows that the same type of vasomotor dysfunction is found in artery segments of rats and humans following ex vivo exposure to E171.

Vascular and molecular pharmacology of the metabolically stable CGRP analogue, SAX.

The main purpose of this study was to compare in vitro pharmacological properties of human αCGRP (CGRP) and a recently discovered metabolically stable CGRP analogue, SAX, in isolated rat and human artery segments. In rat, CGRP and SAX induced similar vasodilatory responses in isolated mesenteric artery with the potency of SAX being lower than that of CGRP (vasodilatory pEC50 8.2 ±â€¯0.12 and 9.0 ±â€¯0.11, respectively). A corresponding difference in receptor binding affinity of SAX and CGRP was determined in rat cerebral membranes (pKi 8.3 ±â€¯0.19 and 9.3 ±â€¯0.14, respectively). CGRP and SAX-induced vasodilation was antagonised with similar potencies by the CGRP receptor antagonist BIBN4096BS supporting a uniform receptor population for the agonists. In human tissue, SAX and CGRP induced similar pharmacological responses with different potencies in subcutaneous artery (vasodilatory pEC50 8.8 ±â€¯0.18 and 9.5 ±â€¯0.13, respectively) and human recombinant receptors (cAMP signalling pEC50 9.1 ±â€¯0.16 and 10.2 ±â€¯0.19). Like in the rat mesenteric artery, both SAX and CGRP-responses were inhibited by the CGRP receptor antagonist BIBN4096BS with similar antagonistic potencies. In conclusion, all pharmacological characteristics of SAX and CGRP in human and rat sources points towards action via a uniform BIBN4096BS sensitive receptor population with the potency of SAX being 5-10 fold lower than that of CGRP.

[Gynaecomastia].

Gynaecomastia (GM) is a benign proliferation of the glandular tissue of the male breast and results from an imbalance between androgen and oestrogen. Pubertal GM is found in 50% and often resolves spontaneously without treatment. GM in adult men can be the first symptom of an underlying disease, and thorough investigation is recommended. Treatment of an underlying cause of GM is the first-line treatment. If GM persists, surgical excision with liposuction can provide excellent results and a low rate of complications.

A core undergraduate curriculum in plastic surgery - a Delphi consensus study in Scandinavia.

BACKGROUND AND AIMS: In recent years, undergraduate medical education has undergone a transition from a speciality-based to a more competence-based training system. Consequently, whilst medical knowledge is rapidly expanding, time for teaching of the surgical specialties is decreasing. Thus, there appears to be a need to define the core competences that are to be taught. The aim of this study was to establish a Scandinavian core undergraduate curriculum of competences in plastic surgery, using scientific methods. METHODS: The Delphi technique for group consensus was employed. An expert panel was recruited from various plastic surgery subspecialties, institutions, and levels of clinical experience, in four Nordic countries (Denmark, Finland, Norway and Sweden). Questionnaires were sent out and answers collected electronically via Google Forms™. Following completion of three predefined rounds of anonymous questionnaires; a final core curriculum competency list was agreed upon based on a consensus agreement level of 80%. RESULTS: Two hundred and ninety-five competences were suggested in the first round. In the second round, 76 competences (33 skills and 43 knowledge items) received a score ≥3.00 on a 1-4 Likert scale. Final agreement in the third round resulted in a list of 68 competences with agreement above 80% (31 skills and 37 knowledge items). CONCLUSIONS: This study proposes the first scientifically developed undergraduate core curriculum in plastic surgery. It comprises of a consensus of competences a recently graduated medical doctor should be expected to possess.

Large Ganglion Cyst with Unusual Location on the Back-A Case Report.

A ganglion cyst is a soft tissue tumor-like lesion filled with colloid material commonly located on the hand and wrist. We report a case of a large ganglion cyst with an unusual location on the back. The patient presented with a mass growing over 2 months measuring 11.2 × 4.7 × 7.2 cm on magnetic resonance imaging. Ultrasound and puncture was attempted twice without achieving drainage. After surgical removal, histologic examination diagnosed the tumor as a ganglion cyst. We conclude that when evaluating a subcutaneous soft tissue mass, regardless of localization, a ganglion cyst may be a differential diagnosis.

[Challenging investigation of a metastatic adnexal cutaneous tumour].

Adnexal cutaneous tumours are very rare. A lack of knowledge about their clinical presentations can lead to prolonged diagnostic investigations and disease progression. This case report presents a challenging investigation of a metastatic malignant adnexal tumour due to misleading histology, immunohistochemical analysis and clinical findings.

Crusted scabies in the burned patient.

The objectives of this study were 1) to describe a case of crusted scabies (CS) in a burned patient, which was primarily undiagnosed and led to a nosocomial outbreak in the burn unit; 2) to analyze and discuss the difficulties in diagnosing and treating this subset of patients with burn injury; and 3) to design a treatment strategy for future patients. Case analysis and literature review were performed. The index patient had undiagnosed crusted scabies (sive Scabies norvegica) with the ensuing mite hyperinfestation when admitted to the department with minor acute dermal burns. Conservative healing and autograft healing were impaired because of the condition. Successful treatment of the burns was only accomplished secondarily to scabicide treatment. An outbreak of scabies among staff members indirectly led to diagnosis. CS is ubiquitous, and diagnosis may be difficult. This is the first report of a burned patient with CS in the English language literature. CS is also highly contagious and may lead to a nosocomial outbreak. Furthermore, CS seems to have a detrimental impact on the burned patient's course of treatment. A scabicide treatment is necessary to guarantee successful treatment of the burns.

[Traumatic abdominal wall hernia]. / Traumatisk ventralhernie.

Traumatic abdominal wall hernias are rare. We describe a case of a handlebar hernia which was initially misinterpreted as a rectus haematoma, and consequently the patient was discharged without any treatment. The patient was admitted two days after with severe pain and computed tomography showed a defect in the abdominal wall. The patient underwent laparoscopic hernial repair with a Goretex mesh after some weeks when the primary tissue damage had subsided.

[Gastroduodenal intussusception causing gastric retention]. / Duodenal invagination som årsag til ventrikelretention.

A case of gastroduodenal intussusception caused by a duodenal lipoma is presented. The condition was characterized by severe upper gastrointestinal retention, epigastric pain and weight loss. The mass was diagnosed by CT scan. The diagnosis was confirmed by operation. The patient was treated successfully by manually reducing the intussusception and resection of the lipoma. Histopathology confirmed the mass to be a pedunculated submucosal lipoma. The patient had an uneventful recovery.