Staged margin control techniques for surgical excision of lentigo maligna.

For melanoma in situ (MIS) arising in chronically photodamaged skin (a.k.a. lentigo maligna, LM), the preferred treatment remains surgical excision. Yet, the standard 5-mm margins of excision recommended for other subtypes of MIS have proven insufficient for LM, due to the its indistinct borders. In this report, authors review specialized surgical techniques for the treatment of LM that focus on meticulous assessment of peripheral margins prior to closure (staged margin control) conducted with analysis of either frozen or permanent histologic sections. Techniques utilizing permanent sections include variations of the ''square'', ''perimeter'', and ''contoured'' excisions, and recurrence rates with these techniques are reportedly low based on short-term follow-up. Similarly, Mohs micrographic surgery (MMS) has been reported to be effective in LM, with recurrence rates generally less than 1% over three-five years of follow-up. In order to simplify margin assessment for MMS, many investigators have begun to rely on intraoperative immunohistochemistry (IHC) to identify melanocytes in frozen sections, and MART-1 is surrently the preferred immunostain for this purpose. Other methods of IHC are currently under investigation. Regardless, surgical methods that employ this degree of margin assessment offer superior cure rates compared to standard excision, and should be seriously considered when encountering patients with LM. Total peripheral margin assessment using staged excisions and analysis of permanent sections appears to be a simple and effective alternative to MMS, especially for institutions that prefer examination of permanent sections to frozen sections.

Hormone replacement therapy in postmenopausal women: urinary N-telopeptide of type I collagen monitors therapeutic effect and predicts response of bone mineral density.

PURPOSE: To assess the ability of the urinary N-telopeptide of type I collagen (NTx) to monitor and predict therapeutic effects of hormone replacement therapy (HRT) in postmenopausal women. PATIENTS AND METHODS: To assess the relationship between baseline or change in NTx (predictive variable), and change in lumbar and hip bone mineral density (BMD; outcome variable), we conducted a 2-year randomized controlled study at academic university and private practice medical centers in 236 healthy women 1 to 3 years postmenopausal; 227 women completed the study. Women received estrogen plus progesterone plus calcium (treated group) or calcium alone (control group). RESULTS: In the treated group NTx significantly (P < 0.0001) decreased, and spine and hip BMD significantly (P < 0.00001 and P < 0.005, respectively) increased; in the control group NTx did not change but BMD decreased significantly (P < 0.01). Subjects in the highest quartiles for baseline NTx (67 to 188 units) or decreasing NTx (-66% to -87%) through 6 months demonstrated the greatest gain in BMD in response to HRT (P < 0.05 and P < 0.005). For every increase of 30 units in baseline NTx the odds of gain in BMD in response to HRT increased by a factor of 5.0 (95% confidence interval [CI] 1.9 to 13.3); for every 30% decrease in NTx through 6 months, the odds of gaining BMD in response to HRT increased by a factor of 2.6 (95% CI 1.6 to 4.4). In the control group an increase of 30 units in mean NTx across the study indicated a higher odds of losing BMD by a factor of 3.2 (95% CI 1.6 to 6.5). A high baseline NTx (> 67 units) indicated a 17.3 times higher risk of BMD loss if not treated with HRT. CONCLUSION: These data support the clinical utility of NTx to monitor the antiresorptive effect of HRT in recently postmenopausal women, and to predict changes in BMD in response to HRT.

Dry powders of stable protein formulations from aqueous solutions prepared using supercritical CO(2)-assisted aerosolization.

We report on the use of a new supercritical carbon dioxide-assisted aerosolization coupled with bubble drying technology to prepare stabilized, dry, finely divided powders from aqueous protein formulations. In this study, the feasibility of this new technology was tested using two model proteins, lysozyme and lactate dehydrogenase (LDH). In the absence of excipients, lysozyme was observed to undergo perturbations of secondary structure observed by solid-state infrared spectroscopy. In the presence of sucrose, this unfolding was minimized. Lysozyme did not, however, undergo irreversible loss of activity, as all lysozyme powders generated by supercritical CO(2)-assisted aerosolization (with or without excipients) regained almost complete activity on reconstitution. The more labile LDH suffered irrecoverable loss of activity on reconstituting after supercritical CO(2)-assisted aerosolization and bubble drying in the absence of carbohydrate stabilizers. LDH could be stabilized throughout the nebulization, drying, and rehydration processes with the addition of sucrose, and almost complete preservation of activity was achieved with the further addition of a surface active agent, such as Tween 20, to the aqueous formulation prior to processing.

Marked bone spur formation in a burn amputee patient.

This report presents an unusual case of a lower extremity burn amputee with a marked degree of bone spur formation. A 17-year-old man suffered 56% body surface area mixed-depth electrical and flame burns, necessitating left below knee amputation. He was admitted to a rehabilitation center 3 months postinjury for pylon fitting and gait training. Difficulty was encountered with poor skin tolerance to weight bearing because of the prominent distal bony margins in the stump. X-rays of the stump revealed a marked degree of linear bone spur formation, extending longitudinally from the distal tibia and fibula with multiple cross-bridges. The spur formation was considered an extensive bony exostosis of unclear etiology. Surgical revision was elected to obtain a stump more suitable for prosthetic tolerance, and to avoid a bulky "bypass" prosthesis. This stump revision enabled the patient to attain independent functional prosthetic ambulation. Although there is evidence of some recurrence of bone spur formation, this remains limited and asymptomatic.

Intra-ocular pressure changes using the laryngeal mask airway and tracheal tube.

Intra-ocular pressure was measured before and throughout airway establishment with either the laryngeal mask airway or tracheal tube. Similar measurements were made on removal of either airway and the amount of coughing noted in the first minute after removal. There was a significantly smaller increase in intra-ocular pressure (p less than 0.001) using the laryngeal mask airway, both on placement and removal, than with the tracheal tube. Postoperative coughing was significantly reduced using the laryngeal mask airway (p less than 0.001). There was a significantly greater rise in heart rate using the tracheal tube (p less than 0.01) probably related to an increased cardiovascular response. The laryngeal mask airway is recommended as an alternative to tracheal intubation in routine and emergency intra-ocular surgery.

Tamulustoxin: a novel potassium channel blocker from the venom of the Indian red scorpion Mesobuthus tamulus.

We have characterized tamulustoxin, a novel 35-amino-acid peptide found in the venom of the Indian red scorpion (Mesobuthus tamulus). Tamulustoxin was identified through a [125I]toxin I screen, designed to identify toxins that block voltage-activated potassium channels. Tamulustoxin has also been cloned by RT-PCR, using RNA extracted from scorpion venom glands. Tamulustoxin shares no homology with other scorpion venom toxins, although the positions of its six cysteine residues would suggest that it shares the same structural scaffold. Tamulustoxin rapidly inhibited both peak and steady-state currents (18.9 +/- 1.0 and 37 +/- 1.1%, respectively) produced by injecting CHO cells with mRNA encoding the hKv1.6 channel.