Electrosurgical debulking of pretibial myxedema of the foot.

Pretibial myxedema or thyroid dermopathy constitutes dermal deposition of mucin, primarily hyaluronic acid and chondroitin sulfate. It is a manifestation of autoimmune thyroiditis, seen more in Graves disease than in Hashimoto thyroiditis. The time delay from treatment of hyperthyroidism to appearance of localized myxedema varies from one month to 16 years (mean 5.13 years). Despite a variety of therapeutic options, failure and relapse rates are high. Therapeutic options reported in the literature include compression, topical and intralesional corticosteroids, oral pentoxifylline, octreotide, rituximab, plasmapheresis, and high-dose intravenous immunoglobulin. We share our experience in two patients who were treated with electrosurgical debulking of selected longstanding myxedematous lesions, with one positive result and one negative result.

Simplified noncultured autologous cell grafting for the treatment of chronic nonhealing ulcers: the six-well plate technique.

Chronic recalcitrant ulcers are associated with severe morbidity, and there are few effective treatment options available. Living skin substitutes are an important form of adjuvant therapy to enhance healing of such wounds. We investigated a novel, simplified, noncultured, autologous, cell grafting procedure, using a six-well plate technique, to treat chronic recalcitrant wounds. This was a prospective pilot study that involved harvesting an ultrathin split-skin graft from the gluteal region, which was washed, separated and prepared in six different wells to obtain an autologous mixture of keratinocytes, melanocytes and fibroblasts; this was subsequently applied directly to the wound using a hyaluronic acid (HA) matrix. Eight patients with a total of 14 ulcers were recruited. The primary endpoint assessed was the percentage of re-epithelialization of the ulcers. Secondary endpoints included quality of life and wound bed indices. At baseline, the median wound surface area was 7.4 cm(2) (mean 17.6 ± 23.6 cm(2) , range 0.5-80.0 cm(2) ) with a median duration of 18 months (mean 70.2 ± 95.9, range 3-216 months). The median wound surface area was reduced by 74.3%, from 7.4-1.9 cm(2) , at the final visit. Overall, 28.3% of the ulcers achieved complete healing, and 71.3% of the ulcers had reduction in wound size. Post-graft, there was also improvement in secondary wound bed parameters and all quality of life domains of the Cardiff Wound Impact Schedule. These results suggest that this noncultured autologous six-well technique might be beneficial for treating recalcitrant ulcers.

[Cutaneous calciphylaxis treated by autologous keratinocytes graft and subtotal parathyroidectomy]. / Nécrose cutanée par calciphylaxie traitée par greffe de kératinocytes autologues et parathyroïdectomie partielle.

BACKGROUND: Cutaneous calciphylaxis, seen most often in dialysis patients, is characterised by skin necrosis, and is a disabling and lifethreatening disease. Despite intensive topical treatment, recourse to parathyroidectomy is often necessary. We report the case of a female patient with skin necrosis due to calciphylaxis: pain and necrotic lesions were controlled by grafting of cultured autologous keratinocytes (Epibase). CASE REPORT: A 75-year-old woman with a 5-year history of dialysis-dependent chronic renal failure secondary to nephroangiosclerosis presented a very painful necrotic ulceration on her left leg. In spite of an autologous patch grafts, the lesions rapidly deteriorated. Laboratory data showed high levels of calcium, phosphate and parathyroid hormone and imaging suggested parathyroidal adenoma. Although cutaneous biopsy was not performed, the diagnosis of cutaneous necrosis due to calciphylaxis with tertiary hyperparathyroidism was established. Treatment consisted of a low-calcium and low-phosphorus diet with autologous keratinocytes grafts (Epibase). After the third application of keratinocytes, the pain disappeared, necrosis ceased and wound healing began. Subtotal parathyroidectomy was performed two months after the start of grafts. At three months, the patient was cured. DISCUSSION: . Calciphylaxis is an obstructive vascular disease secondary to calcification of the arterioles leading to ischemic tissue necrosis. Prompt diagnosis is essential since this disease is disabling and life-threatening due to sepsis and ischemic complications. In our case, autologous keratinocyte grafts allowed pain relief to be achieved within large expanses of cutaneous necrosis after correction of calcium and phosphorus levels, thereby allowing parathyroidectomy to be performed under optimal conditions.

The surgical treatment of necrobiosis lipoidica diabeticorum.

We review the literature on the surgical treatment of necrobiosis lipoidica diabeticorum, and we describe 7 cases treated at Stanford University Medical Center. Experiences with them prompt us to recommend surgical excision of the lesions down to the deep fascia, ligation of the associated perforating blood vessels, and the use of split-skin grafts to cover the defects. There were no recurrences when we did all these things.

Granuloma annulare, nodular type--a subcutaneous pseudorheumatoid lesion in children.

Five cases of patients aged between 2 years 8 months and 5 years 6 months with subcutaneous nodular granuloma annulare are reported. Histologically the lesions resembled rheumatoid nodules, consisting of acellular central areas surrounded by palisading histiocytes. Complete or partial excisions were done for diagnosis. Initially the granulomata were not associated with any symptoms of systemic illness, but one patient with IgG deficiency developed subsequent polyarthritis. Antistreptolysin O, antinuclear antibodies and latex fixation test for rheumatoid arthritis were negative except for one patient with additional erythema nodosum and elevated antistreptolysin level. In the other patients the laboratory data were uncharacteristic. The clinical course may be characterized by spontaneous regression and frequent recurrence. In asymptomatic patients further treatment is not necessary. Patients with progressive disease or elevated inflammatory activity were treated with nonsteroidal antirheumatics. The development of subsequent rheumatoid disease in primarily asymptomatic patients is unlikely, but we recommend further observation by an experienced pediatrician.

Surgical excision of pseudotumorous pretibial myxedema.

Pretibial myxedema is a well-known clinical feature of autoimmune thyroid malfunction and is classically associated with Graves' disease. Its clinical course is frequently not related to the clinical control of the underlying thyroid disease. Treatment is primarily medical, consisting of oral and topical corticosteroids. We present a case of successful local excision of a pseudotumorous manifestation at the dorsum of the foot recalcitrant to multimodal medical and dermatological therapy.

Acute necrotizing fasciitis in childhood.

Acute necrotizing fasciitis is a rare but frequently catastrophic infection of the subcutaneous tissues and fascial sheaths. It is rare in infants and children. The case of a 3 1/2-year-old boy with acute necrotizing fasciitis caused by group A beta hemolytic streptococcus is described.

[Treatment of infected pseudarthroses of the tibia complicated by defects of soft tissues]. / Lechenie infitsirovannykh lozhnykh sustavov bol'shebertsovoi kosti, oslozhnennykh defektom miagkikh tkanei.

On the basis of experience in the treatment of 51 patients with infected false joints of the tibia the authors conclude that local circulatory disorders play the decisive role in the genesis of nonunion of the fracture. The recommended methods for removal of the soft tissue defect by various types of pedicled skin grafts in combination with fixation of the fragments and plastic repair, in some cases, of the false joint zone with demineralized bone allografts made it possible to remove the inflammatory process radically and achieve consolidation in 94% of patients who were operated on.

[Transplantation of pancreatic islet cell cultures in the treatment of suppurative surgical diseases in patients with diabetes mellitus]. / Transplantatsiia kul'tur ostrovkovykh kletok podzheludochnoi zhelezy pri lechenii gnoinykh khirurgicheskikh zabolevanii u bol'nykh sakharnym diabetom.

The authors have analyzed the possibility to use transplantation of the pancreatic islet cell cultures of pig embryos as a method of preoperative preparing patients with type II diabetes mellitus having pyo-surgical diseases.