Plastic surgery in the management of the peripheral vascular ulcer.
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Biomedical subjects
Publications and source records attributed to S Jacobsson.
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When skin specimens are exposed in vitro to L-dopa and catecholamines these substances accumulate in the Langerhans cells where they can be visualized with the histofluorescence method of Falck and Hillarp. Some methodological aspects are discussed and a preliminary study of Langerhans cells in contact allergy is reported.
The usefulness of the formaldehyde (FA) and glyoxylic acid (GA) methods for the fluorescence histochemical demonstration of dopa thioethers has been tested using protein droplet models. Similar fluorescence intensities were recorded from these compounds after either FA or GA treatment. Cysteinyldopa gave a high fluorescence yield similar to that obtained from dopamine and dopa in the FA reaction, whereas gluatitodopa showed a lower, although clearly visible fluorescence. Since the FA method seemed to be the most useful one for demonstration of catechol thioethers, the FA-induced fluorophores of these compounds were further characterized by microspectrofluorometry. The spectral characteristics of the thioether fluorophores (excitation maxima at 420 nm and emission maxima at 480-485 nm) distinguish these substances from dopa and other compounds fluorogenic in the Falck-Hillarp method. Dopa thioethers are proposed to form fluorophores with FA in a manner analogous to that of the primary catecholamines i.e. via low-fluorescent tetrahydroisoquinolines, along two different pathways, to strongly fluorescent 3,4-dihydroisoquinolines and 2-methyl-dihydroisoquinolinium compounds. These dihydroisoquinolines are in a pH-dependent tautomeric equilbrium with their quinoidal forms as reflected by a characteristic spectral shift upon acidification. The results of this study provide the guide-lines for the characterization of fluorogenic compounds in pigment-forming cells.
The histologic features of chronic sclerosing osteomyelitis of the mandible were studied. Four different types of tissue reaction were found to be characteristic of the disease. Histochemical recordings were used in an attempt to facilitate differential diagnosis. Similar types of fibro-osseous lesions and biopsy technique are discussed.
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A newly discovered amino acid, 5-S-cysteinyldopa, present in the urine of healthy subjects is excreted in pathological amounts in many patients suffering from melanoma metastases. Increased excretion of 5-S-cysteinyldopa may be observed before metastases become clinically evident. Determination of 5-S-cysteinyldopa is superior to determination of dopa+dopamine in the diagnosis of melanoma metastases.
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Previous studies have demonstrated a specific cytoplasmic fluorescence in human melanocytes, as well as in pigmented nevi and in malignant melanomas, when the formaldehyde histofluorescence method for visualization of certain catechol and indole derivatives was used. In malignant melanoma two fluorogenic substances, dopa and cysteinyldopa, were found previously. In human melanocytes and benign nevi cells the fluorogenic catechols have so far not been characterized, since chemical analyses are difficult to perform on skin, due to the small amounts of catechols present. However, using split thickness skin quantitative determinations are possible by sensitive fluorometric methods. The chemical analyses of cysteinyldopa showed that in human adult skin most or all was located in the superficial layers. The only specific fluorescence in the thin skin was found in dendritic melanocytes. The findings leave little doubt that cysteinyldopa is stored in melanocytes although the possibility of a concomitant occurrence of other thioethers is not excluded. Nevi and giant nevi were also similarly studied and we found considerable amounts of cysteinyldopa in the nevi. It seems as if the cysteinyldopa is stored in the fluorescent nevi cells. There was no consistent difference in the content of the catechol derivatives between intradermal and compound nevi.
In the city of Malmö with about 250 000 inhabitants and only one hospital, all cases of malignant melanoma are referred to the departments of plastic surgery and radiotherapy. Altogether 304 cases were treated between 1952 and 1971 and all patients were accounted for at the follow-up. This figure does not include cases of superficial melanoma, Hutchinsons melanoma or eye melanoma. The incidence of melanoma increased from 3.4 to 8.0 per 100 000 inhabitants during the period. The treatment was the same during the years. The results of the treatment are presented in relation to the stage of disease, surgical procedure used, site of the tumour and sex. The overall 5-year survival rate without recurrence was 62%, while 6% were alive with recurrence. The corresponding figures for stage I cases were 71% and 7%. Total biopsy of the tumour before more radical surgery was not found to have any disadvantage. In view of the good results, we intend to continue the present method of treatment with addition of adjuvant chemotherapy in the "poor risk" groups.
Debrisan (Pharmacia AB, Sweden) is a highly hydrophilic dextran polymer in the form of dry, spheric beads. When dry Debrisan beads are placed on a wound, the wound secretions are sucked up into and between the beads. No crust is formed on the wound. Bacteria granular substances are removed with the secretions. Treatment with Debrisan was found to be very effective in cleansing discharging wounds. Since Debrisan treatment removes substances from the wound area, e.g. prostaglandins, this might affect the process of repair. The morphology of wounds was studied with the aid of histological and histochemical methods. In 15 patients, donor sites on one thigh, treated with Debrisan, were compared with donor sites on the contralateral thigh, subjected to open treatment. In pigs, comparison was made between Debrisan-treated with Vaseline-gauze-covered dermal burns. In man, the inflammatory reaction was less pronounced in the Debrisan-treated wound and located more superficially then in the wound left open, where perivascular inflammatory cell infiltrates were found even deep in the dermis. In pigs the burns exhibited similar differences. Thus the inflammatory reaction in the Debrisan-treated wounds was less pronounced than in the control wounds. Debrisan beads were never seen below the wound surface. No unfavourable influence of Debrisan treatment was observed on the process of repair.
Debrisan, a highly hydrophilic dextran polymer, was previously shown to be effective in cleaning infected wounds. The dry beads remove wound secretions from the wound surface under gel formation. The gel can then be analysed. A high fibrinolycic activity on fibrin plates and high levels of fibrin/fibrinogen degradation products were found in the secretions from 12 wounds. Low of plasminogen, antithrombin III and the absence of coagulable fribinogen also indicated a high fibrinolytic activity. A higher fibrinolytic activity on heated than on unheated fibrin plates, and the insignificant effect of local application of EACA suggest the presence of other proteolytic enzymes than plasmin.
Dry cross-linked dextran (Sephadex pharmaceutical grade, Debrisan) was applied to weeping sores. After some exudate had been absorbed the gels were removed. The amount of exudate was determined by isotope dilution techniques. The accuracy of the method was tested by determination of plasma proteins in samples of diluted serum containing known concentrations of some plasma proteins. The method seems suitable for determining various high and low molecular weight constituents of exudates.
When dry porous hydrophilic beads, formed by a three dimensional network of dextran polymers, are placed on a discharging wound, they absorb the exudate and swell to form of a gelatinous layer. Within this gelatinous layer a separation of substances occurs according to their molecular weights, with the smaller (MW less than 1000) freely penetrating the pores of the beads and the larger (MW greater than 5 000) remaining in the interspaces. Since proteins are removed from the wound surface with the fluid, crustformation on the wound is prevented. Clotting within the gel layer does not occur, since, as shown in another study (Aberg, Hedner, Jacobsson & Rothman 1976), wound exudate contains a high amount of fibrin-fibrinogen split products and no coagulable fibrinogen. Therefore as long as dry beads are available, exudate can be sucked up. With the wound exudate bacteria, degradation products and toxins are removed from the wound surface. A substance with the above described properties Debrisan (Pharmacia AB, Sweden) was used to treat various types of wounds. The treatment was most effective for profusely discharging infected wounds. Within a few days inflammation subsided, exudate decreased and granulation tissue appeared. So far no side effects are observed and even patients, who during years of treatment of leg ulcers had become sensitized to most dressings and local antibiotics could be treated. The new technique for sampling of wound fluid also offers a model for studies on inflammatory mediators and protein loss.
An account is given of the clinical, radiologic, and pathologic, features of a special form of fibro-osseous lesion of the mandible. The material consists of fifteen cases (eleven females and four males). Two cases are described in detail. Together with Case 1, a probably unique series of radiographic pictures is presented, showing the development of the disease.
Eighty patients were operated upon with subcutaneous mastectomy and reconstruction with prosthesis. Seventy operations were performed on both breasts. The indications used were carcinoma in situ in a previous biopsy, pronounced epithelial proliferations on at least two previous occasions or recurring fibrocystic disease after at least two previous biopsies. Since the autumn of 1971, the operation has been performed as a one-stage procedure and we have had few complications. The appearance of the breasts was evaluated at review 3-60 months after operation. Most patients found the results acceptable or good. The mamilla always lost its sensibility, but the sensibility of the remaining skin of the breast sometimes returned with time. Most of the patients were well satisfied with the procedure and thought it better than any other sort of treatment. The tissues removed were thoroughly studied. Changes in the breasts were often bilateral and pronounced epithelial proliferation and carcinoma in situ were fairly common. Invasive carcinoma was found in 2 instances. The importance of the histologic examination of removed tissues is stressed. A regular follow-up of these patients is important for assessing the value and the risks of subcutaneous mastectomy.
Urinary excretion of 5-S-cysteinyldopa was studied in 9 patients with primary melanoma. All had 5-S-cysteinyldopa excretion in the normal range. In 8 of the patients excretion values decreased after removal of the tumour. Twenty-four patients with clinical signs of melanoma metastasis were examined for 5-S-cysteinyldopa and dopa+dopamine in the urine. 16 of the 24 had pathologically increased excretion of 5-S-cysteinyldopa and 7 of the 24 had pathological excretion of dopa+dopamine. Six of the latter belonged to the group with increased 5-S-cysteinyldopa excretion and one patient had a borderline value of 5-S-cysteinyldopa. Determination of 5-S-cysteinyldopa seems to be of value in the follow-up of patients operated on for primary melanoma.
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