Novel human papillomavirus (HPV) DNA sequences from recurrent cutaneous and mucosal lesions of a stoma-carrier.

Recent studies have demonstrated a high prevalence of human papillomavirus (HPV) types originally believed to be restricted to patients with epidermodysplasia verruciformis (EV) in benign and malignant skin tumors of the general population. Other groups detected typical mucosal HPV in skin tumors. We have investigated recurrent leukoplakial cutaneous and mucosal lesions located around the ileostoma of a woman with ulcerative colitis for the presence of HPV. Cutaneous, mucocutaneous, and mucosal ileostoma-biopsies were analyzed by three different polymerase chain reaction protocols for genital, cutaneous, and cutaneous EV-associated HPV types. Polymerase chain reaction products were cloned, sequenced, and submitted to phylogenetic analyses. HPV-DNA sequences of the EV-HPV group could be detected in all biopsies, whereas genital/mucosal or cutaneous HPV types were not found. HPV types detected comprised HPV20, HPV23, HPV38, and four putatively novel HPV types that belong to different clusters of the EV-HPV group B1. Different HPV types prevailed in cutaneous, mucocutaneous, and mucosal lesions and the number of HPV sequences found per lesion varied between one and three. Our data show the association of recurrent lesions around a stoma and at the ileum with known and novel EV-HPV types. These results emphasize the plurality of HPV and yield data for the possible transmission of cutaneous HPV to mucosal areas of the intestine.

Flashlamp-pumped pulsed dye laser for hemangiomas in infancy: treatment of superficial vs mixed hemangiomas.

OBJECTIVE: To study in a compared manner the efficacy of flashlamp-pumped pulsed dye laser (FPDL) therapy for superficial and mixed hemangiomas. DESIGN: Nonrandomized control trial. SETTING: Department of Lasermedicine, General Hospital Neukölln, Berlin, Germany. PATIENTS: To investigate variation in response to treatment, a prospective study of 165 children with 225 separate hemangiomas treated with the FPDL was undertaken. Patients were aged 2 days to 7 years; mean follow-up was 5 months. INTERVENTIONS: During a 2 1/2-year period, we administered 332 treatments, for a mean+/-SD of 2.0+/-1.1 treatments per patient. MAIN OUTCOME MEASURE: Patients received therapy until the lesion was almost clear or until the lesion did not respond to treatment. Evaluation was performed by comparing pretreatment and posttreatment photographs. In addition, pathologic flow of vessels and thickness were determined before, during, and after completion of therapy with color-coded duplex sonography. RESULTS: In the first group of 100 patients with 153 flat cutaneous hemangiomas, 52 hemangiomas (34%) had excellent results; 80 (52%) had good results; and 21 (14%) showed proliferation of the subcutaneous component, although these lesions were flat at first presentation. Of the 54 mixed hemangiomas, 33 (61%) had continued proliferation of the subcutaneous component. The cutaneous component responded to therapy in 21 hemangiomas (39%), whereas the subcutaneous component of the mixed hemangiomas remained unchanged. No lesions in this group involuted completely, and therapy was discontinued because of relatively poor response. Twelve (67%) of 18 patients with superficial hemangiomas in the involution phase had excellent results and 6 (33%) had good results. CONCLUSIONS: Treatment with the FPDL is effective and may be the treatment of choice for superficial cutaneous hemangiomas at sites of potential functional impairment and on the face. Hemangiomas with a deep component do not benefit from FPDL treatment because the efficacy of the FPDL is limited by its depth of vascular injury. Furthermore, early therapeutic intervention with the FPDL may not prevent proliferative growth of the deeper or subcutaneous component of the hemangioma despite early intervention.

Treatment of congenital tracheoesophageal fistula by endoscopic laser coagulation: preliminary report of three cases.

Three newborns with congenital tracheoesophageal fistula were treated by endoscopic laser coagulation. After radiologic and endoscopic diagnosis, laser coagulation of the mucosal layer of the fistula followed using Nd:YAG laser light transferred through an uncovered quartz fiber of 600 microns diameter. The successful and uneventful course in two cases contrasts with the incomplete obliteration in one case caused by inadequate energy application and/or early localized instillation of contrast medium for radiologic control examination. The advantages of this method include elimination of an operative procedure, exclusion of operative complications, and the possibility of repetition in recurrent cases. Care must be taken to prevent esophageal and tracheal damage by use of this method.

PHACE syndrome: new views on diagnostic criteria.

The association of large facial hemangiomas with posterior fossa malformations and vascular anomalies has been termed the PHACE syndrome. It is characterized by the association of posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and other cardiac defects, and eye abnormalities. Since most articles focus on isolated case reports, an extended retrospective literature review of all reports of large hemangiomas with associated abnormalities of the central nervous system and other malformations was performed to examine the clinical features, and other not as yet reported associated anomalies. Reports were found on 59 patients with PHACE syndrome, to which we added ten cases of our own. The Dandy-Walker syndrome is the most common CNS abnormality reported in association with PHACE syndrome and was seen in 48 (81 %) patients. Arterial malformations were found in 13 (22 %) cases; only 11 patients (19 %) had structural arterial abnormalities without associated Dandy-Walker complex. As published, about one third of patients (31 %) had further ophthalmologic abnormalities, and cardiac anomalies, including coarctation of the aorta. Subglottic hemangiomas were seen in 4 (7 %) patients and ventral developmental defects also in 3 cases. In seven of 59 patients (12 %) with PHACE syndrome, intracranial hemangiomas were present. This study demonstrates that among other CNS abnormalities, special attention should be given to intracranial hemangiomas which seems to be a peculiar phenotype of PHACE syndrome. We therefore suggest that a sixth criterion should be added to the five minimal inclusion criteria for PHACE syndrome. The inclusion criteria would then be: arterial abnormalities or/and intracranial hemangiomas. On the basis of our experience with our patients and with those previously reported, we stress the importance of using contrast-enhanced imaging to detect intracranial lesions.

Association of large facial hemangiomas with Dandy-Walker syndrome. Case study concerning three infants.

Hemangiomas are the most common benign tumors of infancy and are observed in 2-3% of newborns. The Dandy-Walker syndrome is characterized by a cystic expansion of the fourth ventricle, a dysgenesis of the vermis of the cerebellum and atresia of the foramina of Luschka and Magendie. We report on three infants with large bilateral facial hemangiomas in association with a Dandy-Walker syndrome. We conclude that although the three diseases are not based on one common genetic disorder, as far as we know, one should bear this association in mind in cases with large facial hemangiomas.

Diffuse neonatal hemangiomatosis associated with Simpson-Golabi-Behmel syndrome: a case report.

Diffuse neonatal hemangiomatosis (DNH) is a rare disorder characterized by multiple cutaneous and visceral hemangiomas that usually presents in newborns and has a high mortality rate. While previously reported cases of DNH describe multiple cutaneous hemangiomas, we present a patient with a single hemangioma of the ear, who also had DNH of the central nervous system and visceral organs. Furthermore, in this report we present a new constellation of findings, namely, a Simpson-Golabi-Behmel syndrome (SGBS). The practical implication on the basis of the experience with our patient is the need to ensure adequate diagnostics for patients with large hemangiomas as well as for patients with multiple cutaneous hemangiomas, because DNH also can occur in single hemangiomas in rare cases.

[Lasers in medicine]. / Laser in der Medizin.

Laser systems are widely spread in the field of medicine. The applications are divided into therapeutical and diagnostic applications. The main field however are therapeutical procedures. Depending on the indication lasers were used for removing and cutting of smooth and hard tissue or for coagulation. A relative new procedure is the photodynamic therapy. Substances--mostly dyes--are applied to the body and stay for a certain time in tumorous tissue. After an interval it is possible to irradiate this tissue. Only the cells with the incorporated substances react with a cell death.

Consensus Document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management.

Arterio-venous malformations (AVMs) are congenital vascular malformations (CVMs) that result from birth defects involving the vessels of both arterial and venous origins, resulting in direct communications between the different size vessels or a meshwork of primitive reticular networks of dysplastic minute vessels which have failed to mature to become 'capillary' vessels termed "nidus". These lesions are defined by shunting of high velocity, low resistance flow from the arterial vasculature into the venous system in a variety of fistulous conditions. A systematic classification system developed by various groups of experts (Hamburg classification, ISSVA classification, Schobinger classification, angiographic classification of AVMs,) has resulted in a better understanding of the biology and natural history of these lesions and improved management of CVMs and AVMs. The Hamburg classification, based on the embryological differentiation between extratruncular and truncular type of lesions, allows the determination of the potential of progression and recurrence of these lesions. The majority of all AVMs are extra-truncular lesions with persistent proliferative potential, whereas truncular AVM lesions are exceedingly rare. Regardless of the type, AV shunting may ultimately result in significant anatomical, pathophysiological and hemodynamic consequences. Therefore, despite their relative rarity (10-20% of all CVMs), AVMs remain the most challenging and potentially limb or life-threatening form of vascular anomalies. The initial diagnosis and assessment may be facilitated by non- to minimally invasive investigations such as duplex ultrasound, magnetic resonance imaging (MRI), MR angiography (MRA), computerized tomography (CT) and CT angiography (CTA). Arteriography remains the diagnostic gold standard, and is required for planning subsequent treatment. A multidisciplinary team approach should be utilized to integrate surgical and non-surgical interventions for optimum care. Currently available treatments are associated with significant risk of complications and morbidity. However, an early aggressive approach to elimiate the nidus (if present) may be undertaken if the benefits exceed the risks. Trans-arterial coil embolization or ligation of feeding arteries where the nidus is left intact, are incorrect approaches and may result in proliferation of the lesion. Furthermore, such procedures would prevent future endovascular access to the lesions via the arterial route. Surgically inaccessible, infiltrating, extra-truncular AVMs can be treated with endovascular therapy as an independent modality. Among various embolo-sclerotherapy agents, ethanol sclerotherapy produces the best long term outcomes with minimum recurrence. However, this procedure requires extensive training and sufficient experience to minimize complications and associated morbidity. For the surgically accessible lesions, surgical resection may be the treatment of choice with a chance of optimal control. Preoperative sclerotherapy or embolization may supplement the subsequent surgical excision by reducing the morbidity (e.g. operative bleeding) and defining the lesion borders. Such a combined approach may provide an excellent potential for a curative result. Conclusion. AVMs are high flow congenital vascular malformations that may occur in any part of the body. The clinical presentation depends on the extent and size of the lesion and can range from an asymptomatic birthmark to congestive heart failure. Detailed investigations including duplex ultrasound, MRI/MRA and CT/CTA are required to develop an appropriate treatment plan. Appropriate management is best achieved via a multi-disciplinary approach and interventions should be undertaken by appropriately trained physicians.

[Treatment of hemangiomas in infancy and childhood with the flash lamp-pumped dye laser: cutaneous versus mixed cutaneous-subcutaneous hemangiomas]. / Die Behandlung von Hämangiomen im Säuglings- und Kindesalter mit dem blitzlampengepumpten Farbstofflaser. Kutane versus gemischte kutan-subkutane Hämangiome.

The efficacy of flashlamp-pumped pulsed dye laser therapy at 585 nm for cutaneous and mixed hemangiomas was assessed in 165 children with 225 separate hemangiomas were treated in 332 sittings over 2.5 years. The patients were divided into three groups: 100 patients with 153 flat cutaneous hemangiomas, 47 patients with 54 mixed cutaneous-subcutaneous hemangiomas and 18 patients with 18 superficial hemangiomas in the involution phase. In the first group of 100 patients with 153 flat cutaneous hemangiomas, 52 (34%) of the lesions showed total lightening. 21 of the 153 lesions showed proliferation of the subcutaneous component, although these lesions were flat at first presentation. Of the 54 mixed hemangiomas, 33 (61%) had continued proliferation of the subcutaneous component. The cutaneous component responded to therapy in 21 (39%) hemangiomas while the subcutaneous component of the mixed hemangiomas remained unchanged. No lesions in this group involuted completely and therapy was discontinued because of a relatively poor response to therapy. 12 (67%) of the 18 patients with superficial hemangiomas in the involution phase had excellent results, and 6 (33%) had good results. We conclude that treatment with the flashlamp-pumped pulsed dye laser is very effective and may be the treatment of choice for selected hemangiomas, especially cutaneous hemangiomas at sites of potential functional impairment (hands or feet, anogenital-region), and on the face. Furthermore, laser therapy should be initiated as early as possible, even in the first days or weeks of life, when the hemangioma is flat, to prevent enlargement, promote involution, or eliminate these vascular lesions.

Lasers in pediatric surgery.

During the last few years the laser has become a very interesting instrument in pediatric surgery. This is the result of the wide variation in tissue interactions and the possibility of specific applications. The CO2 laser is a highly precise cutting instrument whereas the argon laser has its great advantage in the treatment of superficial vascular anomalies. The most important laser in pediatric surgery is the Nd:YAG laser, on the one hand because its radiation can be transmitted by fibres, on the other because with the relationship between interaction time and power density, and the choice of application, it is possible to change the tissue interaction from precise cutting to specific coagulation and homogeneous coagulation. As a result, indications for lasers in pediatric surgery range from the treatment of superficial haemangiomas to typical endoscopic procedures and the resection of parenchymatous organs and tumours.

Nd:YAG laser procedures in tumor treatment.

Due to the wide variability of tissue interactions and the possibility of specific applications, the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser is the most important surgical laser. With the adequate choice of application mode and relationship between interaction time and power density, it can be used for precise cutting in the contact mode with the bare fiber, with either a wide or small coagulation seam. With a handpiece a precise focal coagulation for preparation and hemostatic purposes is possible, as well as cutting with the focussed noncontact beam where additionally a wide coagulation seam is necessary. Endoscopically guided coagulation, vaporization, and cutting are possible with bare fibers which can be introduced through nearly all endoscopes. With increasing importance, the possibility for wide and homogeneous volume coagulation is used to destroy diseased tissues either by noncontact irradiation or interstitial placement of the fiber. Thus, the field of laser application in tumor therapy ranges from the treatment of superficial tumors to endoscopic tumor ablation, resection of neoplastic tissue in parenchymatous organs, and interstitial thermotherapy with coagulation of deep-seated primary and secondary malignancies. With its different application modes the laser can be used as a surgical instrument or as a central therapeutical method, whereby perfect control of tissue interactions is always possible by using either visual control for superficial and endoscopic procedures or magnetic resonance imaging and color-coded duplex sonography as a control for interstitial procedures. During 12 years of clinical work we have developed several application modes and have proved the Nd:YAG laser to be an effective instrument in tumor therapy.

Creation of a caecostoma in mice as a model of an enterocutaneous fistula.

In the past, physiological, oncological and pharmaceutical investigations led to the development of different models of enterocutaneous fistulas. For a few years, fistula models were also created to investigate the efficacy of minimal invasive therapies in closing these fistulas. As most experimental surgical procedures are difficult to perform and are often combined with a high mortality or spontaneous closure rate, a new model in mice was developed with the aim of avoiding these disadvantages. Twenty mice, divided into two groups of 10 animals each, had a caecostoma created surgically. The two groups differed regarding the technique of creating the stoma. All animals survived and gained weight during a postoperative period of 4 months. The operation was easy to perform and lasted no longer than about 30 min. Neither a spontaneous closure of the fistula nor any prior death of animals occurred. In conclusion, because of its simplicity and low complication rate, the presented model of an enterocutaneous fistula may offer an interesting alternative to other models for a variety of indications.

[Selection of various types of lasers in the treatment of surface and deep vascular anomalies]. / Auswahl verschiedener Lasertypen bei der Behandlung von oberflächlichen und tiefen Gefässanomalien.

Laser therapy can be used to great advantage in the treatment of haemangiomas in childhood in specially selected cases. We were able to collect experiences in 101 children and to utilise both the coagulation effect for percutaneous induction of regression and the cutting effect in the resection of haemangiomas at the body surface and the thoracic and abdominal cavities. Among the commercially available laser equipment we would prefer the argon laser for intracutaneous lesions (naevi teleangiectatici, spider naevi, plane haemangiomas), whereas for the cavernous or planotuberous or tuberonodous haemangiomas it is better to use the neodym-YAG laser. Patients must be very carefully selected and selection must be restricted to haemangiomas with complications. Treatment via neodym-YAG laser must be complemented by protecting the skin against cold, by compressing the angiomas and by an appropriate after treatment.

[Use of laser in vascular surgery]. / Laseranwendungen in der Gefässchirurgie.

The use of lasers in the field of vascular surgery concerns 3 completely different principles of application. The main field is the therapy of hemangiomas and congenital vascular diseases (CVD). The experience of the therapy of congenital diseases can be also used in the treatment of varicosis, especially in the treatment of the perforating veins. In contrast to the angioplasty, where the therapeutic aim is recanalisation of an arterial vessel, in the venous system it is the occlusion of a vessel. The thermal procedures using argon- or Nd:YAG lasers with hot tips, saphire tips or with the bare fiber are no longer relevant. Only photoablation using pulsed lasers is able to remove calcified material. The excimer laser is currently the best known system for angioplasty. New developments, for example solid state lasers like the holmium laser, have as yet to show their advantages. A main emphasis of research should be the improvement of catheter systems since present applications are limited by those currently available catheter systems. Tissue fusion is still an experimental procedure. There is a lot of basic research to be done to establish this procedure in the clinical routine.

Techniques for endoscopic and non-endoscopic intracorporeal laser applications.

This article deals with various designs of CO2 and Nd:YAG lasers currently used in surgery. It is discussed how their wavelength and beampath characteristics can be utilized in either the contact or the non-contact method to achieve specific clinical aims. These may concern endoscopic procedures, e.g. palliative tumour destruction or haemangioma or cystic membrane coagulation, or non-endoscopic procedures, as exemplified by two case reports on treatment for a congenital vascular disorder and varicosis, respectively. As there is a certain overlap of laser and high-frequency applications, their respective advantages and drawbacks are compared in detail. The main safety concern in HF surgery is that of errant currents in the patient, whereas in laser applications the main hazard is to the operators' eyes. This hazard can be safely eliminated.

Percutaneous endoscopic laser discectomy (PELD). A new surgical technique for non-sequestrated lumbar discs.

Basic features and techniques of percutaneous endoscopic laser discectomy are described and the results in 6 patients reported. Indications are: discogenic radicular symptoms, caused by disc protrusions, which do not respond to conservative treatment. Contra-indications are: major neurological deficit, segmental instability and spondylolisthesis, extruded disc prolapse, narrow spinal canal or lateral recess.

Laser-induced weal and flare reactions: clinical aspects and pharmacological modulation.

BACKGROUND: Among the adverse effects of cutaneous laser therapy, weal and flare reactions immediately after treatment have received little attention, and the pathomechanisms are unclear. OBJECTIVES: To study clinical features and possible mechanisms of laser-induced weal and flare reactions in order to identify means of possible therapeutic intervention. METHODS: Normal skin from the inner arm of 20 volunteers was treated with an argon laser, and the size of weal and flare reactions was measured over a 60-min period. Skin biopsies were taken from four volunteers before and up to 24 h after laser treatment and examined histologically and immunohistologically. Possible underlying mechanisms were also explored using various topical or systemic pharmacological agents. RESULTS: Wealing was noted in 19 of 20, and flare reactions in all volunteers, with peak values at 15 min. Skin biopsies showed central coagulation of the tissue, cleft formation between epidermis and dermis, normal numbers of morphologically intact mast cells on toluidine blue staining close to the lesion, and only minor upregulation of endothelial and leucocyte adhesion molecules. In agreement with these findings, pretreatment with acetylsalicylic acid, the H1-blocker loratadine and triamcinolone cream was ineffective or resulted in a non-significant reduction of weal and flare reactions. In contrast, local anaesthetics as well as neuropeptide depletion of skin with capsaicin abolished the reactions almost completely. CONCLUSIONS: Transient weal and flare reactions in response to laser treatment occur in almost all persons and are based primarily on a neurogenic rather than a histamine- or mast cell-dependent mechanism.

Is endometrial ablation a safe contraceptive method? Pregnancy following endometrial ablation.

A case of pregnancy following thermal endometrial ablation is presented in this report.