Multiple Previous Treatments Research Articles

Treatment of rosacea-like demodicidosis with oral ivermectin and topical permethrin cream

A 32-year-old man presented with a chronic rosacea-like dermatitis of the facial skin and the eyelids. The skin disorder had been present for 4 years and was unresponsive to multiple previous treatment attempts. Skin scrapings and a histologic examination of a biopsy specimen from the affected area revealed the presence of numerous Demodex mites. The patient was treated with oral ivermectin and subsequent topical permethrin resulting in complete and rapid clearing of the folliculitis. We believe that this case supports the view that Demodex mites may be pathogenic when they are present in large numbers. Oral treatment with 200 μg/kg ivermectin with subsequent weekly topical permethrin showed impressive treatment efficacy in a case refractory to conventional treatment. (J Am Acad Dermatol 1999;41:775-7.)

The relationship between faecal bile acid profile with or without supplementation with calcium and antioxidants on recurrence and growth of colorectal polyps.

Faecal bile acids (FBA) have been implicated in colon carcinogenesis. The results of case-control studies of colorectal cancer and polyp patients are, however, conflicting. The aim of this study was to examine the influence of faecal bile acids on occurrence, growth and recurrence of colorectal polyps, and to see if a mixture of calcium and antioxidants might possibly act on cancer precursors through the effect on FBA. A total of 116 polyp-bearing patients were recruited from the outpatients department. Polyps < 10 mm in diameter were left in situ and measured by annual colonoscopy for 3 years. The patients received placebo or a mixture of antioxidants and calcium carbonate, 1.6 g calcium ion daily. Faecal samples were collected annually; the first, 1 month after start of intervention, freeze dried and subjected to bile acid profile analysis. Two age and sex matched control groups were recruited (n = 35), one from healthy volunteers (healthy controls) and one from the outpatients referred for colonoscopy, with no polyps (hospital controls). Twelve of 47 patients from the healthy volunteers had polyps (healthy polyp patients). One or more adenomas were found in 93 patients. The faeces of the hospital controls had significantly higher concentrations of total and secondary bile acids than did the healthy controls. There was no difference in FBA profile between the polyp group and the hospital controls, but significantly higher concentration of total and secondary faecal bile acids in the healthy polyp patients compared with the healthy control group (P < 0.05). No increased concentration of FBA were found in the polyp patients with multiple polyps (n = 21) or previous treatment for colorectal cancer (n = 7). No associations between FBA profile and growth or recurrence of colorectal polyps were found. The polyp patients receiving active medication had higher faecal concentrations of total and secondary bile acids in the beginning of the study than at the end, in spite of a good compliance. The present study does not support bile acids as being important markers of initiation or growth of small and medium sized colorectal adenomas. In the present study the calcium and antioxidants did not seem to affect the growth or recurrence of colorectal adenomas by increased TBA excretion in the faeces.

Use of distal splenorenal shunt in children referred for liver transplant evaluation

Variceal bleeding remains a common cause of morbidity for children with both intrahepatic and extrahepatic portal hypertension. Occasionally, patients referred for liver transplant evaluation have significant variceal bleeding, despite adequate synthetic liver function. During a 7-year period, 322 children were referred for liver transplant evaluation. Six underwent distal splenorenal shunt surgery after evaluation. There were four boys and two girls. The average age was 11 ± 4 years, and the average weight was 39 ± 15 kg. The etiology of variceal bleeding was intrahepatic portal hypertension in five (1 biliary atresia, 2 chronic hepatitis, 2 congenital hepatic fibrosis) and extrahepatic portal vein thrombosis in one. Two patients had no previous attempts at sclerotherapy (one because of an abnormality in platelet function, the other because of extensive gastric varices), and four had multiple previous sclerotherapy treatments. No patient had preoperative encephalopathy. Three cases were Child's class A, and three were Child's class B. Preoperative evaluation of the portasystemic system was performed with magnetic resonance (MR) imaging or splenoportography. All patients underwent a distal splenorenal shunt procedure, four of whom also had splenopancreatic disconnection. One patient required 100 mL of blood replacement, and five required no blood. The average length of hospital stay was 9.8 ± 2.2 days. Postoperative complications were minimal. All patients are alive, without recurrent gastrointestinal bleeding or encephalopathy, and they have patent shunts, which was confirmed by MR or Doppler ultrasound at a mean of 25 ± 20 months after shunt surgery. Children who have significant cirrhosis, portal hypertension, recurrent variceal bleeding refractory to sclerotherapy, and adequate synthetic function can be effectively treated with a distal splenorenal shunt. While the choice between liver transplantation of shunting may be difficult, use of the distal splenorenal shunt does not preclude future liver transplantation for such children.

Self-help quit smoking interventions: Effects of self-help materials, social support instructions, and telephone counseling.

Smokers requesting self-help materials for smoking cessation (N = 2,021) were randomized to receive (a) an experimental self-quitting guide emphasizing nicotine fading and other nonaversive behavioral strategies, (b) the same self-quitting guide with a support guide for the quitter's family and friends, (c) self-quitting and support guides along with four brief counselor calls, or (d) a control guide providing motivational and quit tips and referral to locally available guides and programs. Subjects were predominantly moderate to heavy smokers with a history of multiple previous quit attempts and treatments. Control subjects achieved quit rates similar to those of smokers using the experimental quitting guide, with fewer behavioral prequitting strategies and more outside treatments. Social support guides had no effect on perceived support for quitting or on 8- and 16-month quit rates. Telephone counseling increased adherence to the quitting protocol and quit rates.

Basal Cell Carcinoma Recurring after Radiotherapy: A Unique, Difficult Treatment Subclass of Recurrent Basal Cell Carcinoma

Twenty-seven basal cell carcinomas (BCCs) recurring following radiation therapy alone or in addition to other treatment modalities were treated with Mohs micrographic surgery (MMS) from 1983 to 1989. Mean tumor size was 2.1 cm. Of the tumors, 70.4% arose in the mid-face region, 55.6% had undergone multiple previous treatment modalities. The present recurrence rate is 7.4% (mean follow-up: 25 months). Basal cell carcinoma recurring following radiotherapy deserves special subclassification among recurrent BCC. It is very difficult to eradicate, with high recurrence rates following standard surgical excision or further radiotherapy. Tumors are usually large, aggressive, and invasive. Most arise in the cosmetically crucial mid-face region, where extension into subcutaneous tissue planes is common. Mohs surgery, with its inherent abilities to examine all margins, map tumor extension, and conserve tissue, is uniquely suited to treatment of these difficult tumors.

Proximal femurectomy for decubitus ulceration in the spinal cord injury patient

The results of proximal femoral resections in nine patients were analyzed after an average four year follow-up, together with a retrospective analysis of the patients. The indication for surgery was decubitus ulceration that had failed to respond to multiple previous treatments. The decubitus ulcers were associated with septic arthritis, osteomyelitis, hip dislocation and ankylosis. All patients achieved short term healing with 50% achieving long term healing. The incidence of subsequent surgery for decubitus ulcers decreased significantly. No patient suffered a deterioration in function.