Hemodynamic changes during conventional and daylight photodynamic therapy of actinic keratoses - a randomized controlled trial.

BACKGROUND: Photodynamic therapy (PDT) is an effective treatment for actinic keratosis (AK). However, pain and hypertension are important side effects of conventional PDT (c-PDT). Several studies have demonstrated that daylight PDT (dl-PDT) is less painful while being as effective as c-PDT. OBJECTIVE: To observe the effect of c-PDT and dl-PDT on different hemodynamic parameters (systolic blood pressure and diastolic blood pressure, pulse rate, and peripheral oxygen saturation). METHODS: Fifty patients with AK on the head were enrolled into this prospective, randomized, controlled study and treated with c-PDT or dl-PDT in a 1:1 ratio. Hemodynamic parameters were measured at four different time points during treatment. Pain was quantified using a visual analog scale. AK was counted before treatment and after one month. RESULTS: C-PDT is associated with significantly more pain, a significant increase in blood pressure and a higher rate of patients with grade 3 hypertension. Whereas dl-PDT is almost painless and does not lead to any changes in hemodynamic parameters. For both treatments, a similar lesion response rate was found after one month. CONCLUSIONS: dl-PDT has a better tolerability while being as effective as c-PDT and therefore may be the more favorable treatment option in certain patient groups.

Pain management in photodynamic therapy using a nitrous oxide/oxygen mixture: a prospective, within-patient, controlled clinical trial.

BACKGROUND: Photodynamic therapy is an effective treatment for actinic keratoses. Nevertheless, severe pain during the procedure is a serious adverse effect, which leads to interruption or even termination. Complete pain relief remains a difficult challenge. OBJECTIVE: To evaluate the effect of a nitrous oxide/oxygen mixture on pain intensity during photodynamic therapy. METHODS: This clinical trial has been designed as a prospective, single-centre, explorative, controlled, observational study. RESULTS: We were able to detect a significant overall pain reduction of 55.2% after application of a nitrous oxide/oxygen mixture by means of an intra-individual comparison. Furthermore, the total number of therapy interruption significantly decreased by 82% after the inhalation analgesia. Additionally, treatment satisfaction ranged from 'extremely to very satisfied'. CONCLUSIONS: This study shows that analgesia by means of a nitrous oxide/oxygen mixture is a very effective and well-tolerated method for achieving significant pain reduction during photodynamic therapy.

Retrospective analysis evaluating the effect of a keratolytic and physical pretreatment with salicylic acid, urea and curettage on the efficacy and safety of photodynamic therapy of actinic keratoses with methylaminolaevulinate.

BACKGROUND: Photodynamic therapy (PDT) is a highly effective treatment option for actinic keratosis (AK). Hyperkeratosis of the AK impairs penetration of the photosensitizer and light and leads to a reduced efficacy of PDT. Therefore, it is commonly recommended to perform curettage of the AK prior to treatment. OBJECTIVE: This observational, monocentric, retrospective study sets out to compare the effects of curettage (CUR), chemical keratolytic pretreatment with salicylic acid 10% (SA), and urea cream 40% (UR) on the efficacy and tolerability of PDT. METHOD: A total of 44 subjects aged 73.2 ± 7.7 years (mean ± SD) with multiple AKs (mean 11.1 per patient) in face and scalp were analysed. In 15 patients, CUR was performed prior to PDT while 15 and 14 patients underwent keratolytic pretreatment with SA and UR, respectively, 1 day prior to PDT. All patients underwent one session of methylaminolaevulinate (MAL) PDT using a 630-nm LED lamp at 37 J/cm(2) , pain was measured using a visual analogue scale. The response rate was calculated using the documented number of AKs prior and 4 weeks after PDT. RESULTS: Mean lesion response rates were 68.5%, 61.4% and 60.8% for CUR, SA and UR respectively. Differences were not significant. Patients with SA or UR experienced significantly more pain (SA: 6.3 ± 2.7, P = 0.02; UR: 6.1 ± 1.8, P = 0.04) than patients with curettage (4.4 ± 2.1). The cosmetic result and the patients' satisfaction 4 weeks after PDT were good to excellent in all three groups without a significant difference. However, pretreatment with SA or UR led to pronounced local reactions compared to CUR. CONCLUSION: Keratolytic therapy with SA or UR is an effective pretreatment for PDT. However, it leads to an increase in pain during PDT and pronounced local reactions.

[Generalized erythrosquamous dermatosis]. / Generalisierte erythrosquamöse Dermatose.

A 21-year-old man presented with generalized erythema, erosions and hyperkeratoses since birth. Histology revealed epidermolytic hyperkeratosis with degeneration of the upper epidermis and perinuclear deposits of abnormal keratin aggregations. Epidermolytic ichthyosis was diagnosed. This congenital Ichthyosis occurs due to mutations of keratin 1 or 10 genes that leads to defects of intra- and intercellular structural integrity in the spinous and granular layers with compensatory hyperkeratosis. After childhood, life expectancy is normal but lifelong therapeutic and skin care measures are required.

Acute hepatitis C virus in an HIV clinic: a screening strategy, risk factors, and perception of risk.

Acute hepatitis C virus (HCV) infection is being acquired undetected among HIV-infected individuals. A practical way to regularly screen HIV-infected patients for acute HCV irrespective of perceived risk or symptoms is needed. We piloted implementation of an acute HCV screening strategy using routine HIV clinical care schedules and the least costly blood tests, in a Rhode Island HIV care center. Study participants had ongoing HCV risk, completed questionnaires encompassing risk behaviors and perception of risk, and were screened with quarterly alanine aminotransferase (ALT). ALT rise triggered HCV RNA testing, with pooled rather than individual specimen HCV RNA testing for underinsured participants. Participants were primarily older, college-educated men who have sex with men (MSM) with history of sexually transmitted infection other than HIV. One of 58 participants developed acute HCV in 50 person-years of observation for an annual incidence of 2.0% per year (95% confidence interval [CI] 0.05-11.1%). The majority (54%) of MSM did not perceive that traumatic sexual and drug practices they were engaging in put them at risk for HCV. Unprotected sex often occurred under the influence of drugs or alcohol. Self-reported HCV risk and participation in several risk behaviors declined during the study. It was possible to collect frequent ALTs in a busy HIV clinic with 71% of total projected ALTs obtained and 88% of participants having at least one ALT during the 9-month follow-up period. All instances of ALT rise led to reflexive HCV RNA testing. Tracking quarterly ALT for elevation to systematically prompt HCV RNA testing before seroconversion is a promising approach to screen for acute HCV in a real-world HIV clinical setting.

Gouty panniculitis in a 68-year-old man: case report and review of the literature.

BACKGROUND: Gouty panniculitis is a very rare disease. To date, only eight patients have been reported. In each case, time to diagnosis was lengthy. We describe a 68-year-old man with a 6-month history of tender, erythematous plaques and nodules involving the anterior aspects of the legs. METHODS AND RESULTS: Histologic examination led to the diagnosis of gouty panniculitis. CONCLUSION: Review of the literature and the present case suggests that hyperuricemia is a necessary but probably not sufficient condition for gouty panniculitis. Why gouty panniculitis very seldom arises as a manifestation of gout is puzzling. In almost all reported patients, uricostatic or uricosuric therapy leads to clinical improvement of the disease.

[Verrucous tumor of the amputation stump]. / Verruköser Tumor am Amputationsstumpf.

Epithelioma cuniculatum (EC) belongs to the category of verrucous carcinomas. Invasiveness and rate of metastasis are low, but there is a high risk of local recurrence. In cases of long-standing processes with formation of exophytic, malodorous tumors with jagged edges that do not respond to conventional therapy, consideration should already be given to EC upon visual inspection. The diagnosis is always established by histological examination. The standard treatment of EC is extensive excision of the tumor with micrographic margin control.

Successful treatment of systemic-sclerosis-related digital ulcers with a selective endothelin type A receptor antagonist (sitaxentan).

Digital ulcers represent a major vascular complication of systemic sclerosis (SSc) and can be difficult to treat with the common vasodilators. Herein, we report on a 39-year-old patient with recalcitrant SSc-related digital ulcers treated successfully with sitaxentan (100 mg q.d.), a selective endothelin type A receptor antagonist. During the 6 months of treatment, we noticed a remarkable decrease in pain, a nearly complete healing of the preexistent ulcers and no development of new ulcers. No side effects were noted.

Long-term efficacy and safety of once-daily nevirapine in combination with tenofovir and emtricitabine in the treatment of HIV-infected patients: a 72-week prospective multicenter study (TENOR-trial).

BACKGROUND: There is an unmet medical need for simplified antiretroviral therapy regimens to improve patient's compliance and quality of life. The purpose of this study was to evaluate the efficacy and safety of a once-daily regimen with Tenofovir (TDF), Emtricitabine (FTC) and Nevirapine (NVP) for adult patients with HIV-1 infection. METHODS: 70 patients were enrolled in a prospective, multicenter, non-randomized, single arm, open-label cohort study. Patients were either naive or had problems with their current ART and needed to be changed to another regimen. Daily drug dosage was 300 mg Tenofovir, 200mg Emtricitabine and 400 mg Nevirapine once daily. Follow-up was performed over 72 weeks. RESULTS: After 72 weeks, the regimen was still continued by 52 patients (74,3%). Of these, 44 patients (84,6%) had a viral load below detection limit. The median viral load had decreased by 2,5 log and the median CD4 cell count had increased by 44,8%. Most side-effects occurred at an early stage during the study. Resistances were rare (only two resistances were considered as newly developed) and occurred rather late during the study. CONCLUSION: A once-daily regimen of Tenofovir, Emtricitabine and Nevirapine is an attractive treatment option since it is safe, effective, and well tolerated.

Successful surgical management of giant condyloma acuminatum (Buschke-Löwenstein tumor) in the genitoanal region: a case report and evaluation of current therapies.

Giant condyloma acuminatum (GCA; Buschke-Lowenstein tumor) is a human-papillomavirus-induced cauliflower-like tumor of the genitoanal region. It is characterized by its size, capability of local infiltration and high recurrence rate. We report on a 50-year-old patient presenting with a maximum finding of GCA with deep infiltration into the adductor and perineal musculature, the scrotum, the penis and the para-rectum. After performing a temporary loop colostomy, the tumor was removed by wide radical excision following plastic reconstruction with a myocutaneous gracilis flap. During a follow-up period of more than 5 years, no recurrence developed. Many treatment strategies (e.g. chemotherapy, radiation) have been published in the literature. Most authors recommend the radical surgical excision, allowing a complete histological examination and assessment of tumor-free resection margins. Despite the benign histological pattern of GCA in most cases, transformations into verrucous carcinoma and squamous-cell carcinoma have been described. In our case, the GCA seems to represent a continuum between normal condyloma acuminatum and an initial verrucous carcinoma.

Predictive relevance of soluble CD44v6 serum levels for the responsiveness to second line hormone- or chemotherapy in patients with metastatic breast cancer.

Concentrations of soluble CD44 standard (sCD44std) and CD44 variant 6 (sCD44v6) isoforms were determined in the sera of 59 patients with distant metastasis from breast cancer receiving second line hormone- or chemotherapy, in comparison to 46 breast cancer patients without detectable recurrent disease and 21 healthy blood donors. The sera of non-metastatic breast cancer, patients contained sCD44std and sCD44v6 concentrations similiar to those of healthy blood donors. In sera of patients with distant metastasis from recurrent breast cancer the median values of sCD44std and sCD44v6 were significantly higher (sCD44std: 502 ng/ml, p=0.03; sCD44v6: 193 ng/ml, p = 0.002) in comparison to healthy blood donors and patients with non-metastatic disease (p<0.001 for both parameters). A significant correlation was observed between sCD44v6 serum concentrations and the number of metastasized organs (p=0.0018), serum LDH concentrations (p<0.0001), tumor grading (p=0.025) and the presence of hepatic metastasis (p=0.028). Furthermore, sCD44v6 expression was associated with the patient's responsiveness to second line hormone- or chemotherapy. Non-responders had significantly higher sCD44v6 levels compared with the responder group (median: 447 ng/ml vs 171 ng/ml; p=0.0007). Logistic regression analysis indicated that sCD44v6 serum levels above 250 ng/ml (p =0.033) and the presence of hepatic metastasis (p=0.009) were independent factors predicting an unfavourable response to therapy.