Access to bacteriophage therapy: discouraging experiences from the human cell and tissue legal framework.

Cultures of human epithelial cells (keratinocytes) are used as an additional surgical tool to treat critically burnt patients. Initially, the production environment of keratinocyte grafts was regulated exclusively by national regulations. In 2004, the European Tissues and Cells Directive 2004/23/EC (transposed into Belgian Law) imposed requirements that resulted in increased production costs and no significant increase in quality and/or safety. In 2007, Europe published Regulation (EC) No. 1394/2007 on Advanced Therapy Medicinal Products. Overnight, cultured keratinocytes became (arguably) 'Advanced' Therapy Medicinal Products to be produced as human medicinal products. The practical impact of these amendments was (and still is) considerable. A similar development appears imminent in bacteriophage therapy. Bacteriophages are bacterial viruses that can be used for tackling the problem of bacterial resistance development to antibiotics. Therapeutic natural bacteriophages have been in clinical use for almost 100 years. Regulators today are framing the (re-)introduction of (natural) bacteriophage therapy into 'modern western' medicine as biological medicinal products, also subject to stringent regulatory medicinal products requirements. In this paper, we look back on a century of bacteriophage therapy to make the case that therapeutic natural bacteriophages should not be classified under the medicinal product regulatory frames as they exist today. It is our call to authorities to not repeat the mistake of the past.

Systemic anaplastic large cell lymphoma presenting with cutaneous manifestations in a young man: a case report.

Skin lesions can be a sign of internal disease. When they are associated with persisting systemic signs, the possibility of an internal malignancy should always be considered. We describe a 25-year-old man who presented with weight loss, fatigue, subpyrexia, xerostomia and skin rash of 6 months duration. Physical examination showed a dry red skin, most prominent in the face, the palms of the hands and the soles of the feet. Laboratory investigations revealed signs of inflammation and a high level of antinuclear antibodies. Retroperitoneal lymph nodes were visualized on a CT scan of the abdomen. CT-guided biopsy of an abdominal lymph node revealed the presence of an anaplastic large cell lymphoma (ALCL), ALK-positive. A biopsy of the skin showed non-specific signs of inflammation.The patient underwent 8 cycles of chemotherapy according to the CHOP protocol. A complete remission was obtained. Non-Hodgkin lymphoma can indeed be associated with skin lesions. They result from direct invasion by malignant cells or are of paraneoplastic origin, as was the case in this patient.

Recurrent contagious ecthyma (Orf) in an immunocompromised host successfully treated with cryotherapy.

A 48-year-old patient under immunosuppressive therapy for renal transplantation had contagious ecthyma which relapsed after excision. Stable healing was obtained by cryotherapy.

Subcorneal pustular dermatosis treated with PUVA therapy. A case report and review of the literature.

BACKGROUND: Subcorneal pustular dermatosis (SPD) is a chronic recurrent pustular dermatosis of unknown etiology. Many treatments have been proposed, none of which has been uniformly successful. OBJECTIVE: Our purpose is to report a patient with SPD successfully treated by PUVA and to review the literature concerning phototherapy treatment of SPD. METHODS: A patient suffering from SPD resistant to diaminodiphenylsulphone (dapsone) responded well to a combination therapy consisting of dapsone and PUVA. He received 50 mg/day and 3 PUVA sessions a week. Photographs were taken at baseline and after 15 sessions. RESULTS: The lesions were virtually cleared after 15 sessions. The patient remained free of lesions with a maintenance therapy of dapsone (50 mg/ day) and 1 PUVA session a week. CONCLUSION: The therapeutic value of phototherapy for the treatment of SPD still has to be confirmed and could be a valuable alternative for treatment-resistant patients.

Skin microcirculation responses to severe local cooling.

When skin is exposed to cold, cutaneous blood flow is initially restricted due to sympathetic vasoconstriction. Prolonged exposure to cold has a secondary protective vasodilator effect. In the present study, the effects of severe and prolonged local cold on the cutaneous microcirculation were assessed. In 10 young healthy subjects, laser Doppler skin flux and flux motion were measured at the calf during 20 min of local ice cooling and 15 min subsequent recovery. In the 6th minute of cooling, mean skin flux decreased to 58 +/- 6% of the resting value (p < 0.05), then increased and reached 129 +/- 10% of the resting value at the end of the cooling period, followed by a phase of reactive hyperemia with a maximum of 225 +/- 24% (p < 0.05). Mean flux motion frequency, spontaneously present at rest with a frequency of 2.6 +/- 0.2 cycles/ min decreased rapidly during the first minutes of cold exposure, was absent during the 6th to the 10th minute, reappeared and started to increase from the 11th minute and reached 4.4 +/- 0.3 cycles/min during the recovery period (p < 0.05). This study seems to indicate that the phenomenon of protective increase of cutaneous microcirculatory blood flow consists of an initial phase of vasodilation, followed by a phase of active and enhanced microvessel vasomotor activity.

Laser Doppler flux characteristics at the skin of the dorsum of the foot in young and in elderly healthy human subjects.

In aged human subjects the cutaneous circulation has shown reduced vasoreactive capacity when stimulated by heat or ischemia, and autonomic dysfunction developing in the elderly was suggested. Should this autonomic dysfunction affect the arteriolar vasomotional activity, it might be demonstrated by laser Doppler fluxmetry (LDF) at rest. LDF flow motion characteristics at the dorsal foot skin were investigated under resting conditions in two subject groups differing in age. The younger group (n = 27, aged 25-29 years) showed a resting flux of 3.0 +/- 1.0 Arbitrary Units (AU) and a flux amplitude of 0.34 +/- 0.13 AU. In the elderly group (n = 22, aged 60-92 years) both these values were significantly (P < 0.05) lower (2.4 +/- 0.5 and 0.18 +/- 0.05 AU, respectively). The flux frequency, on the contrary, was similar in both age groups: 4.9 cycles min-1. We conclude that the mean resting flux and the mean flow motion amplitude under resting conditions at the skin of the dorsum of the foot are significantly reduced in an old-age group. The latter finding might be an aging phenomenon affecting the microvascular tone and reactivity, and might be one of the elements responsible for the attenuated cutaneous vasoreactivity described in elderly humans in response to heat and ischemic stress.

Healing of full-thickness wounds in pigs: effects of occlusive and non-occlusive dressings associated with a gel vehicle.

This study, based upon a pig model, was conducted to investigate the effects of moist and dry healing conditions on wound closure (epithelialization, granulation tissue, contraction) of full-thickness wounds. Thirty-two full-thickness square wounds (3 cm x 3 cm) covered with either an occlusive polyurethane dressing (Tegaderm) or a non-occlusive dressing (Melolin) were evaluated. The effect of the presence or the absence of a gel (3% Idroramnosan) was also investigated with both dressings. The dressings were renewed twice a week. The time required for wound closure was 19.2 +/- 1.6 days for Tegaderm and 26.6 +/- 3.0 days (means +/- SD) for Melolin, respectively. The healing time of the full-thickness porcine wounds was significantly (P < 0.001) reduced by the occlusive dressing. Equivalent results were found with the 3% gel, indicating that the gel can be used as a neutral vehicle. The healing rate, calculated according to Gilman's method, was also significantly (P < 0.001) enhanced by the occlusive dressing. This progression was 0.073 +/- 0.004 cm/day and 0.050 +/- 0.009 cm/day (means +/- SD) for Tegaderm and Melolin, respectively. The contribution of contraction to wound closure was similar in all wounds, indicating that the occlusive dressing did not have an effect on wound contraction. Histological evaluation was performed on full-thickness skin biopsies of whole wound harvested from the time of wound closure to 3 months after. At any time point, no significant histological variations were observed between the different treated wounds. This study demonstrates in a porcine model that for full-thickness wounds, as for split-thickness wounds, occlusive dressing enhances healing rate and shortens the time for wound repair. The shortened healing time is a function primarily of the effect of occlusive dressing on epithelialization, especially the third phase of wound resurfacing.

Vesiculopustular eruption associated with mycoplasma pneumoniae pneumopathy.

A 43-year-old Caucasian male, hospitalised with a severe Mycoplasma pneumoniae infection of the respiratory tract developed subcorneal pustular dermatosis. After 3 months of treatment with dapsone 50 mg daily, all skin lesions disappeared without recurrences.

Acute generalized exanthematous pustulosis induced by paracetamol. A case with severe hemodynamic disturbances.

We report on a 28-year-old Bangladesh man with acute generalized exanthematous pustulosis, induced by paracetamol. The patient presented with an erythematous and pustular eruption after taking 1 tablet of paracetamol for a sore throat. After intravenous administration of propacetamol hydrochloride (which is a prodrug of paracetamol), the rash became worse, showing a toxic epidermal necrolysis-like appearance and the patient suffered from severe hemodynamic disturbances. After discontinuation of propacetamol hydrochloride, the eruption cleared within 2 days. Prick testing performed in the patient revealed a positive reaction for propacetamol hydrochloride.

Unusual clinical manifestation of a disfiguring necrobiotic granulomatous disease.

A 39-year-old woman had a disfiguring granulomatous disease of 36 years' duration. Nodules appeared on her lower extremities and later extended to her face; this led to ulceration and destruction of the nasal cartilage. This disease of unknown origin does not conform to any previously described entity. Some patients with a similar case presentation have been observed in France.

Healing of full-thickness wounds treated with lyophilized cultured keratinocyte cell lysate in genetically diabetic mice.

The effect of a lyophilized cell lysate prepared from cultured human keratinocytes on the healing of full-thickness wounds was evaluated in an impaired healing model. Full-thickness wounds (8 mm in diameter) were made on the dorsal areas of female genetically diabetic mice C57 BL/KsJ (db/db) and their normal (db/+) littermates. Wounds were covered with an occlusive polyurethane film dressing and were treated for 5 days either with the lyophilized cell lysate from cultured human keratinocytes prepared in phosphate-buffered saline solution or with phosphate-buffered saline solution. In normal (db/+) mice, all wounds were closed 16 days after wounding, and more than 90% of the wound closure was due to wound contraction. Wound contraction accounted for a similar extent of wound closure in both lyophilized cell lysate-treated and phosphate-buffered saline solution-treated wounds. In contrast, in the diabetic (db/db) mice, after histologic examination of the wounds 32 days after wounding, four of ten lyophilized cell lysate-treated wounds and four of seven phosphate-buffered saline-treated wounds were found to be closed. Moreover, applications of lyophilized cell lysate from cultured human keratinocytes to full-thickness wounds in diabetic db/db mice significantly decreased the contribution of contraction to wound closure. Day 32 after wounding, contraction contribution to wound closure amounted to 57.7%+/- 4.7% and 80.4%+/- 3.2% (mean +/- standard error of the mean, p < 0.005) of the initial wound areas, respectively, for lyophilized cell lysate-treated and phosphate-buffered saline solution-treated wounds. At this time of wound healing, the thickness of the dermis was increased 1.7-fold by the keratinocyte cell lysate treatment, but neither epithelial migration from the wound edges nor the thickness of the regenerated epithelium were significantly affected. In conclusion, in diabetic (db/db) mice the application of lyophilized cell lysate from cultured human keratinocytes influenced the healing of the dermis and wound contraction, but had no effect on reepithelialization.

Antibiotic prophylaxis for infectious complications after therapeutic endoscopic retrograde cholangiopancreatography: a randomized, double-blind, placebo-controlled study.

We performed a randomized, double-blind, placebo-controlled trial of antibiotic prophylaxis before diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in 82 uninfected patients with cholestasis due to biliary tree obstruction of single or multiple causes. The patients were assigned to receive piperacillin (4 g) or placebo three times daily; prophylaxis was started just before initial ERCP and was continued until biliary drainage was completely unobstructed (by one or more ERCP procedures); the maximal duration of prophylaxis was 7 days. Nine patients were withdrawn from the study, and five others could not be assessed because of protocol violations. The 68 clinically evaluable patients underwent 81 therapeutic ERCP procedures. Clinical success (defined as an absence of fever, cholangitis, and clinical signs of sepsis during the 48 hours after the last dose of piperacillin or placebo) was documented for 32 (94%) of the 34 patients given piperacillin and for 24 (71%) of the 34 patients given placebo (odds ratio, 6.66; P = .01). Complete biliary drainage influenced clinical outcome favorably (odds ratio, 5.0; P = .02). All seven instances of bacteriologic failure (bacteremia) involved patients in the placebo group (P < .01). We concluded that antimicrobial prophylaxis significantly reduces the incidence of septic complications after therapeutic ERCP among patients presenting with cholestasis.

Randomized trial comparing cryopreserved cultured epidermal allografts with hydrocolloid dressings in healing chronic venous ulcers.

BACKGROUND: Cultured epidermal allografts have been successfully used to treat a variety of wounds. Their postulated mechanism of action is through release of cytokines that stimulate epithelialization. On the basis of previous experience we expected ulcers treated with cryopreserved cultured allografts (CCAs) to be healed by 6 weeks. Hydrocolloid dressings (HCDs) have also been reported to be effective in the treatment of venous ulcers. OBJECTIVE: Our purpose was to compare the effectiveness of CCAs with HCDs in healing chronic venous ulcers. METHODS: Forty-three patients with 47 ulcers were enrolled in a randomized controlled trial. Ulcers not healed by 6 weeks were changed to the other treatment. RESULTS: No difference in the number of healed ulcers between the two groups was observed at 6 weeks. Healing rate, percent reduction of initial ulcer size, and radial progression toward wound closure were significantly greater for CCAs than for HCDs. Pain relief was not significantly different. CONCLUSION: CCAs achieve more rapid healing and greater reduction in ulcer size than HCDs.