T6 positive cells in the peripheral blood of burn patients: are they Langerhans cells precursors?

Peripheral blood mononuclear cells of 14 patients suffering thermal injury were separated by affinity chromatography on peanut agglutinin (PNA) coupled to Sepharose macrobeads. The resulting PNA positive subset was 14% of the total mononuclear population. About 30% of these cells were found to coexpress T6(CD1), Ia-like and the myeloid differentiation antigens My4(CDw14) and Mo1(CD11). In comparison, the PNA+ subset from normal blood donors (about 5% of total mononuclear cells) contained mature monocytes that were found to be T6 negative. Electron microscopic studies using immunogold labeling showed that the T6 positive cells were slightly smaller than monocytes but larger than the classical lymphocytes and had common morphologic features with the Langerhans cells of the skin. Considering that patients suffering extensive damage of the epidermis require fast renewal of all skin elements, it is possible that the cells we identified in their peripheral blood are the precursors of the Langerhans cells of the skin en route from bone marrow to the epidermis.

Temperature monitoring during photodynamic therapy of skin tumors with topical 5-aminolevulinic acid application.

Temperature monitoring during photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) cream application was performed on 22 patients with solar keratoses (SK) and basal cell carcinoma (BCC). The lesions were located on the forehead, nose, ear and cheek. Temperature measurements during photoirradiation, with a power density of 100 mW/cm2 from an incoherent light source (light delivery system for PDT), were carried out by noncontact (infrared thermal imaging radiometer) and contact (thermocouple) methods. Thermal imaging analysis revealed nonuniform temperature distribution in the irradiated areas. The temperature gradually increased from the peripheral to the central zone of the area. The results showed that photoirradiation induced heating of the skin tumors to 39.5-42.5 degrees C during the PDT procedure. The temperature of normal skin areas disposed symmetrically to the lesions on the contralateral side at the same conditions of irradiation (without prior ALA application) was about 42-43.5 degrees C. The surface temperature differences (delta T) between the normal and tumor tissues after 10 min of irradiation were 3.3 +/- 0.5 degrees C in the forehead areas, 2.5 +/- 0.4 degrees C in the nose areas and 0.8 +/- 0.3 degrees C in the ear areas.

Postoperative catheterization and prophylactic antimicrobials in children with hypospadias.

A prospective study of 78 children who underwent 84 operations for correction of hypospadias was done. Of these, 54 had a transperineal indwelling Foley catheter for ten days after surgery and 30, a transurethral catheter. Forty-five randomly selected children received prophylactic antimicrobial therapy (sulfamethoxazole), and the remaining 39 children served as controls. Incidence of urinary tract infection was significantly higher in the control group (10 of 39) as compared with the treated group (3 of 45) in spite of the higher incidence of vesicoureteral reflux in the treated group. This suggests that prophylactic antimicrobial treatment may prevent urinary tract infection from prolonged indwelling catheterization.

Vesicoureteral reflux in boys with hypospadias.

Hypospadias in a congenital anomaly which in most cases has to be corrected surgically. We include micturition cystourethrography (MCU) in the preoperative workup of all these children as well as three months postoperatively. Meatal stenosis and müllerian duct remnants are known to occur in this condition, but vesicoureteral reflux (VUR) was an unexpected finding in many boys who were asymptomatic and had no evidence of urinary tract infection. Fifty-eight of 305 hypospadiacs, examined by MCU, proved to have reflux, most of them grade II. In 37, VUR was found before surgery and in the remaining 21 after surgical correction, many of them with meatal stenosis. In 10 patients reflux appeared in the postoperative period where there had been none in the preoperative study; 8 of the 10 had a postoperative stricture of the distal urethra, and VUR subsided in 4 after adequate dilatation. We conclude that vesicoureteral reflux is not uncommonly found in patients with hypospadias, even in those who are completely asymptomatic. We believe this is an additional incentive to include an MCU in the pre- and postoperative evaluation of patients with this anomaly.

Microcystic adnexal carcinoma following radiotherapy in childhood.

A 36-year-old man was treated by radiotherapy for tinea capitis many years before discovery of microcystic adnexal carcinoma (MAC). Because of patient's refusal of any surgical intervention, we were able to follow the natural course of this tumor for 13 years. This case emphasizes the typical slow development of (MAC). The implication of the association of MAC and radiotherapy are discussed.

Neck contracture as a rare complication of cervical soft tissue expansion.

An unusual complication using an inflatable silicon implant for removing postburn scarred tissue of the neck and face is described. The appearance of a fibrotic band along the inflating tube caused neck contracture. The purpose of this article is to present this uncommon complication and to emphasize the technical error when using the tissue expander in the neck region.

Burn patients' use of autohypnosis: making a painful experience bearable.

Autohypnosis (that is performing hypnosis in the absence of the therapist) was used for adjuvant analgesic and anxiolytic therapy in 18 burn patients. It combines the advantages of hypnosis without being limited by the availability of the hypnotic therapist immediately prior to painful activities. Autohypnosis is less time and labour consuming, and therefore less expensive. Out of 180 patients treated with autogenic relaxation techniques only 48 (27 per cent) entered a state of hypnosis that enabled them to cope with their pain, and 18 (10 per cent) achieved autohypnosis. Most of these patients needed some auxiliary devices such as recorded instructions or telephone calls.

Postburn peroneal nerve palsy--a report of two consecutive cases.

We report two patients suffering from mixed deep partial and full skin thickness flame burns covering 45 and 95 per cent of the total body surface area respectively. These patients, following sepsis and multisystem failure, developed unilateral peroneal nerve palsy. The possible aetiology of isolated injury to the peroneal nerve in burned and critically ill trauma patients is discussed.

Thermal osteonecrosis complicating Steinmann pin insertion in plastic surgery.

Two typical cases of thermal osteonecrosis due to Steinmann pin insertion are presented. Using proper technique, including predrilling or the use of a hand drill, can eliminate the high morbidity problem.

Restoration of sensation to the hand by a free neurovascular flap from the first web space of the foot.

A neurovascular free flap from the first web space of the foot was used successfully in two patients for replacement of glabrous skin of the hand and fingers. The potential advantages of this flap are that (1) it may be used to replace large defects of glabrous skin, (2) it provides a rich vascular supply to the periphery of the hand, and (3) the sensation achieved approaches the normal for the intact glabrous skin of the hand.

Hair-bearing neck flap for upper-lip reconstruction in the male.

Reconstruction of the upper lip resulting in a hair-bearing area and a non-hair-bearing lining is described in two cases of full-thickness lip defects. A unipedicled neck flap was used in one case and a bipedicled neck flap in the other, both comprised of hair-bearing and adjacent non-hair-bearing areas. The neck flap has the advantages of providing the two layers of the lip, and the reconstructed lip is not too thick and is mobile and pliable, and the hair resembles lip hair in color, density, and quality. The multiple operative procedures can be performed under local anesthetic.

Hypospadias repair with subcutaneous suture and tissue adhesive for surface closure.

A combination of a running P.G.A. subcutaneous suture, reinforced by butyl-cyanoacrylate tissue adhesive for surface bonding of the skin, has enabled us to reduce our rate of fistula formation by about 50 percent in hypospdias repairs by the Denis Browne two-stage or the Horton-Devine one-stage procedure.

A comparison between K-wire and compression screw fixation after arthodesis of the distal interphalangeal joint.

Thirty patients underwent arthrodesis of the distal interphalangeal (DIP) joint for various injuries. Fixation with K-wires was compared to fixation by compression screws. The screw method came to be preferred by us, principally because the immobilization time was significantly less and the patients returned to work more quickly. The success rate of fusion and the time required for it were about the same.

Neovascularization of skin flaps: route and timing.

Axial flaps were elevated in a pig and rat model. Selective ligation of the vascular pedicles on days 1 to 7 following elevation of the flap demonstrated total necrosis of all flaps when the pedicles were ligated on the first, second, and third postoperative day in the pig, and up to 6 days inthe rat. Pedicle ligation beyond this time did not produce flap necorsis, indicating the establishment of adequate neovascularization for flap survival. Selective ligation of the artery or vein did not appear to be significant in the pig. In the rat flap, however, survival tended to occur sooner. Adequate neovascularization for flap survival was demonstrated as arising from both the wound edges and the bed, although vascular channels occurring from the bed appeared to be of greater importance. The relatively rapid rate of neovascularization that occurs for adequate flap survival suggests that if some way could be found to maintain flap viability during the first week, the feeding vessels need no longer remain patent and may be ligated or used for other purposes. This interesting observation has already allowed very early successful defatting of clinically transferred flaps.

Camouflaging hairless areas on the male face by artistic tattoo.

Marked improvement in the aesthetic appearance of scars and skin grafts of the hair-bearing facial areas of male patients can be achieved by camouflage with punctate tattooing. The technique is easy and simple to learn. The procedure is performed under local anesthesia and on an outpatient basis.

The value of angiography prior to use of the latissimus dorsi myocutaneous flap.

In 5 patients studied, preoperative angiography showed the thoracodorsal artery to be patent in two--both of them then had successful transfers of latissimus dorsi myocutaneous flaps. Obliteration of this artery was apparent in 3 patients, precluding the operation. We suggest that selective preoperative angiography be performed in all patients in whom a latissimus dorsi myocutaneous flap transfer is being considered, as a patent thoracodorsal artery is essential to the success of this procedure.

Multiple linear spiradenomas.

A case of eccrine spiradenoma (ESA) is described in a 35-year-old man. During an 18-year period, the original number of tumors grew in size and fused into large groups. Surgical excision of all tumors was performed successfully. The unusual features of the case were a linear distribution and giant multifocal tumors. The histology of the tumors and their appearance at the beginning and 18 years later is described.

Cystourethrography as an aid in the evaluation of hypospadias and its complications.

We report the use of micturating cystourethrography to demonstrate complications of the urethra in hypospadias. We recommend MCU to evaluate hypospadias, both before and after the surgical repair.

Heat tolerance in patients with extensive healed burns.

Some thermoregulatory parameters of 10 subjects with healed burns were studied. The subjects, 4 of whom had healed burns of over 40 percent (group A) and 6 with burns smaller than 30 percent (group B) were assigned in a climatic chamber to 3 hours bench stepping (30 cm height) under 40 degrees C and 50 percent relative humidity. Rectal temperature, weighted skin temperature, heat storage, and heart rate were all found to be significantly higher in group A than in group B or group C (control group of normal subjects). No significant difference was observed between groups B and C. A highly significant linear correlation (r = 0.89) was found between the sweat rate and percentage of burned area. In addition, 3 subjects of group A terminated the study after less than 90 minutes. Two subjects in group B terminated the study after 120 and 135 minutes, while all subjects of group C finished the entire 3 hour work. The study indicates that subjects with burns of over 40 percent could be classified as heat intolerant due to a pronounced reduction in perspiration area.

Imprint cytology in the intraoperative diagnosis of malignant melanoma.

Imprints were prepared from 73 pigmented skin lesions, 19 of which were diagnosed as malignant melanoma. The cytologic findings in malignant melanoma, large clusters of cells with loss of cellular cohesiveness and large pleomorphic nuclei, were positive in 17 of the 19 cases. In other malignant and benign pigmented lesions the few cells adherent to the glass showed characteristic cytologic features of the particular lesion. Imprint cytology seems to be a valuable adjunct to the examination of frozen sections for the intraoperative diagnosis of malignant melanoma.