Paweł Brzewski

The role of focal infections in the pathogenesis of psoriasis and chronic urticaria.

Introduction The Focal Infection Theory, originally presented at the beginning of the 20th century, postulates that systemic diseases can be caused by microorganisms that arise from the focus of infection. Foci of infections have been described as sinuses, adenoids, tonsils, teeth, genitourinary tract, gall bladder and kidneys. A focus of infection is defined as the area that can occur in any part of the body, contains a pathogen (microorganism) and is usually asymptomatic. There are discordant opinions about the role of focal infections in the pathogenesis of psoriasis and urticaria. Aim To establish whether there is a higher incidence of focal infections in patients with chronic urticaria and psoriasis. Material and methods We retrospectively reviewed 129 patients with a history of psoriasis and chronic urticaria: 58 women and 71 men treated in the Department of Dermatology of the Jagiellonian University Medical College in Krakow. Results In the analyzed group, 11 patients had a dental consultation, 58 – laryngological consultation and 29 women had a gynecological consultation. The most common examples of focal infection were tonsillitis, upper respiratory tract infections, sinusitis, dental caries and genitourinary tract infections. Aggravating factors were similar to previously described. Conclusions A high incidence of focal infections in patients with psoriasis and urticaria suggests that infections may play a significant role in the pathogenesis of these skin disorders. Treatment of infection foci may play the key role in the remission of skin changes.

Expression of metalloproteinases (MMP-2 and MMP-9) in basal-cell carcinoma

The aim of this study was to compare the expressions of mRNA for metalloproteinases (MMP-2 and MMP-9) and type IV collagen in two different histological types of basal-cell carcinoma (BCCs; nodular and infiltrative) and in normal tissues from the tumor interface. The study included biopsy specimens of the skin involved with BCC and normal skin adjacent the lesion. The expressions of mRNA for MMP-2, MMP-9 and type IV collagen were determined by means of RT-PCR (Reverse transcription polymerase chain reaction). The level of type IV collagen mRNA in nodular and infiltrative BCCs turned out to be significantly lower, and the expressions of MMP-2 and MMP-9 mRNA significantly higher than in normal tissues adjacent to these tumors. The expression of mRNA for MMP-9 but not for MMP-2 was significantly higher in infiltrative BCCs than in the nodular BCCs. In turn, normal tissues adjacent to nodular BCCs showed significantly higher levels of mRNA for MMP-2 and significantly lower levels of type IV collagen mRNA than the normal tissues from the interface of infiltrative BCCs. The findings suggest that MMP-2 and MMP-9 could be used as prognostic factors of BCCs.

Effects of nanoporous anodic titanium oxide on human adipose derived stem cells

The aim of current bone biomaterials research is to design implants that induce controlled, guided, successful, and rapid healing. Titanium implants are widely used in dental, orthopedic, and reconstructive surgery. A series of studies has indicated that cells can respond not only to the chemical properties of the biomaterial, but also, in particular, to the changes in surface topography. Nanoporous materials remain in focus of scientific queries due to their exclusive properties and broad applications. One such material is nanostructured titanium oxide with highly ordered, mutually perpendicular nanopores. Nanoporous anodic titanium dioxide (TiO2) films were fabricated by a three-step anodization process in propan-1,2,3-triol-based electrolyte containing fluoride ions. Adipose-derived stem cells offer many interesting opportunities for regenerative medicine. The important goal of tissue engineering is to direct stem cell differentiation into a desired cell lineage. The influence of nanoporous TiO2 with pore diameters of 80 and 108 nm on cell response, growth, viability, and ability to differentiate into osteoblastic lineage of human adipose-derived progenitors was explored. Cells were harvested from the subcutaneous abdominal fat tissue by a simple, minimally invasive, and inexpensive method. Our results indicate that anodic nanostructured TiO2 is a safe and nontoxic biomaterial. In vitro studies demonstrated that the nanotopography induced and enhanced osteodifferentiation of human adipose-derived stem cells from the abdominal subcutaneous fat tissue.

Suspicion of pulmonary embolism during treatment of pemphigoid gestationis

Pemphigoid gestationis (PG), first described in 1872 by Laws Milton, is a rare autoimmune bullous disease of pregnancy and puerperium. Pemphigoid gestationis has been estimated to occur in 1: 50 000 pregnancies and usually presents in the second or third trimester with exacerbation after partum. This disease is caused by circulating IgG1 immunoglobulin against hemidesmosomal protein bullous pemphigoid BP180 (BPAG2) type XVII collagen and less frequently BP230. We present a case of pemphigoid gestationis in primigravida with complications during treatment due to the suspicion of pulmonary embolism.

Level of inflammatory cytokines tumour necrosis factor α, interleukins 12, 23 and 17 in patients with psoriasis in the context of metabolic syndrome

Introduction Psoriasis is a chronic inflammatory skin disease with immunologic etiology. Aim To investigate the levels of the proinflammatory cytokines tumor necrosis factor α (TNF-α), interleukin 23 (IL-23) and IL-17 in patients with psoriasis and psoriatic arthritis with concomitant metabolic syndrome. Material and methods This study included 60 patients with severe psoriasis. Results In patients with arterial hypertension concomitant with psoriasis, no statistically significant differences in cytokine levels were observed. On the other hand, in the group of patients diagnosed with diabetes, an increased level of IL-17 was observed. In patients with lipid disorders, the results were similar to the results of patients with diabetes. Conclusions It is very important to study immunologic mechanisms responsible for the presence and severity of psoriasis, in order to personalize the therapy in the future and optimize the effect of action on the basic disease and on concomitant disorders.

Paragangliomas of head and neck – A surgical challenge

Paragangliomas of the head and neck region are rare and predominantly asymptomatic tumors. These neoplasms arise from widely distributed paraganglionic cells, which originate from both mesodermal elements of third branchial arch and the neural crest residues. Despite the rare occurrence of paragangliomas, problems encountered in their diagnosis, unclear malignancy and treatment ensure that they still remain in the focus of head and neck surgeons. This is a retrospective study of the medical records of patients treated in the ENT Department of the 5th Military Hospital in Krakow during the period 2010-2014. All the preoperative, intraoperative and postoperative data were carefully analyzed for each patient. Thirteen patients (16 tumors) were treated during the study period. All the patients with a pre-operative suspicion of paraganglioma underwent computed tomography angiography. The whole cohort of patients was treated surgically. Paraganglioma should be always considered in the differential diagnosis for painless neck masses. These tumors require thorough radiological pre-operative evaluation and skilled operative technique. Surgical treatment occurs to provide good cure rates with minimal recurrence and morbidity rates.

The use of CO2 laser in skin complications following BAHA implantation: our experience in the eight patients

1 Skin reactions are the most common complications after BAHA implantation. 2 The excess of soft tissue leads to inability to tack the hearing ad to the abutment which prevents the effective use of sound processor. 3 This is a prospective case series of 8 patients with skin overgrowth around the BAHA abutments treated with CO2 laser. 4 This case-series suggest that CO2 laser is safe and easy method for the treatment of the skin overgrowth around the BAHA abutment. 5 This is the first case series presentation of the CO2 laser surgery for treatment of the skin overgrowth around the abutment of BAHA This article is protected by copyright. All rights reserved.

Extensive, neglected basal cell carcinoma of the half of the face-surgical treatment and reconstruction with an anterolateral microvascular thigh flap

Basal cell carcinoma (BCC) is the most common malignancy in humans [1, 2]. According to the Skin Cancer Foundation, estimated 2.8 million cases are diagnosed annually in the US. Non-melanoma skin cancers (NMSC), the most common neoplasms in Europe, the USA and Australia, despite their low mortality, pose a serious therapeutic, social and economic problem. Worldwide incidence is increasing by about 10% per annum, so the prevalence of basal cell tumor in the near future will equal that of all other cancers together [3]. Basal cell carcinoma occurs in 85–90% of cases on the head, often on the face above the line connecting the mouth corner with the ear lobe [4]. They are less often found in the lower part of the face and on the scalp. In 10–15% of cases, BCC is found on the neck, trunk and limbs. Location of the basal cell carcinoma is closely related to the exposure to ultraviolet radiation [5, 6]. Although rarely metastatic, it has potential of tremendous, in some locations, life-threating, regional destruction and disfigurement [7]. Diseases on the surface of the skin are usually visible and tend to be easily noticed both for health-care professionals and for patients themselves. However, cases of neglected, extensive skin neoplasms are still a fairly common phenomenon in the 21st century. There are several different methods of treatment of BCC tumors: surgical (simple excision, Mosh’ micrographic surgery), destructive (cryosurgery, curettage and cautery) and non-surgical (photodynamic therapy, radiotherapy, topical-5-fluorouracil, imiquimod) [8, 9]. An advantage of surgical proceeding is the possibility of meticulous histological examination of the tumor type and margins of excision to establish clearance. Early treatment produces cure rates of almost 100% (the suggested overall 5-year cure rates for primary and recurrent BCC are 99% and 94.4%, respectively) [10, 11]. In order to decide on the adequate treatment option, several factors should be taken into consideration: biological, histopathological and clinical features of the neoplasm as well as the patient condition. Exact determination of the skin cancer margins is of particular importance in case of lesions developing in areas where the reoperation of a recurring neoplasm would not be possible. When excision is incomplete, the recurrence rate is approximately 30% [12]. Basal cell tumors are easily treated in their early stages. The larger the tumor has grown, however, the more extensive the treatment is needed. Especially some locations (eyelids, nose flap, lips, auricle) pose a challenge for the surgeon to remove the tumor entirely with proper margins and at the same time retain functionality and satisfactory aesthetic appearance. Furthermore, large, neglected tumor, especially located in the face region, demands complex reconstructive procedures after excision, i.e. local reconstruction techniques, free grafts, advanced, island, pedicle or microvascular flaps. A male patient, aged 66, was admitted to the Department of Otolaryngology of the 5th Military Hospital in Krakow due to large, progressive neoplastic ulceration of the right side of his face. He reported 9-year history of a slowly but gradually growing ulcerating lesion of the right buccal region. Three months before admission, he started to suffer from stabbing pain in the lower part of his face, leaking of saliva and bites of food through the ulceration, disturbances in nutrition, and unintentional, significant weight loss (approximately 15 kg in the past 12 months). The patient was in good general condition (concomitant diseases were benign prostate hypertrophy, left inguinal hernia treated surgically in 1994), evaluated as Fitzpatricks skin photo type II, abusing nicotine. Physical examination revealed extensive, full-thickness ulceration of the right buccal region extending upward to the zygomatic arch, with destruction of the half of the upper lip and one third of the lower lip, infiltrating surrounding mimic muscles, exposing the bone of the body of the mandible, invading the mucosa of the alveolar rim of the mandible (Figures 1 and ​and2)2) [1, 2]. Figure 1 Large, neglected basal cell carcinoma of the right facial region Figure 2 Large, neglected basal cell carcinoma of the facial region In the histological samples taken from the ulceration basal cell carcinoma with perineural infiltration was revealed, but the planoepithelial component could not be excluded. The computed tomography (CT) scans revealed an extensive tissue loss and the possibility of infiltration of the mandible in the region of the right mental foramen. The patient was qualified to the surgical treatment (Figures 3 and ​and44). Figure 3 Harvesting of the musculocutaneous anterolateral thigh flap Figure 4 Microvascular anastomosis with facial vessels The first part of the procedure consisted of resection of the tumor within the histologically clean margins-right buccal region, 1/2 of the upper lip, 1/3 of the lower lip, segmental resection of the right body of the mandible, dental extraction (teeth: 41–45, 12–14) and elective right neck dissection of lymph nodes I–V and submandibular gland (RND (I–V + SG)). The non-lymphatic structures were spared (with special concern for internal jugular vein and facial vessels). The post resection mandible loss was bridged with titanium miniplate. The abundant soft tissue defect was reconstructed with a combination of autologous split-thickness skin graft from the left thigh and microvascular musculocutaneous (based on vastus lateralis muscle) free flap antero-lateral part of the right thigh [3]. Vascular pedicle (6 cm long) consisted of one artery and two veins (diameter approximately 2 cm). The microvascular end-to-end anastomosis was made to the right facial vessels [5]. Evaluation of the patency of the anastomosis was made – the blood flow was satisfactory. In the postoperative care, the patient was monitored every 4 h (general condition, flap color, warmth, pin prick) administered with the analgesics, wide-spectrum antibiotics, low-molecular-weight heparin, nourished by the nasogastric tube. In the eleventh [6] week of the post-operative period he underwent a minor procedure under local anesthesia of the reconstruction of the mouth (Figures 5 and ​and6)6) [7]. Figure 5 Eleven weeks after surgery Figure 6 Reconstruction of the mouth Fifteen weeks after surgery he did not complain of pain, he gained weight of approximately 8 kg, the esthetic outcome was satisfactory. Skin tumors are generally visible and noticeable not only for health care workers but also for the patients themselves. However typical BCCs are indolent and slowly progressive. These tumors remain painless and unobtrusive for long time. In addition, for non-specialists in skin diseases, BCC sometimes resembles noncancerous skin conditions such as psoriasis, eczema or others. The natural history of this cancer makes it an “ideal candidate” for neglected tumor. An extremely important issue in the treatment of locally advanced tumors is the choice of the appropriate method of treatment. Numerous alternatives are available for small BCC lesions: surgical excision, Mosh micrographic surgery, photodynamic therapy, cryosurgery, immunotherapy, and radiotherapy are the most common techniques. The treatment of expansive, neglected tumors, however, often demands a multidisciplinary approach. The treatment of choice for advanced cancers is usually surgery (also neurosurgery, cranio-maxillo-facial surgery, plastic surgery) sometimes combined with radiation therapy. The key point is also the choice of the most beneficial type of reconstructive treatment after ablation of the tumor. The goal is to restore the functionality and esthetically satisfactory appearance, especially after surgery of the tumors of the head and neck with possibly small sacrifice of other tissues [13]. One of attractive reconstructive methods for large defects are free microvascular flaps. Microsurgery has evolved to focus on functional and aesthetic results, as well as donor site morbidity. The qualities of an ideal soft tissue flap for reconstructions in the head and neck region are versatility in design, adequate tissue stock, specific texture, long pedicle with an appropriate diameter of vessels, possibility of two team approach, consistent anatomy, easy and safe dissection and minimal donor site morbidity. One of the alternatives is the anterolateral thigh flap (ALTF). It could be elevated as a cutaneous or musculocutaneous flap (based on vastus lateralis muscle) [14]. It has relatively constant anatomy, which makes dissection safe and easy for a skilled surgeon. Large and long pedicle, with a diameter close to potential recipient vessels of the head and neck make the microvascular anastomosis safe and easy. Harvesting ALTF is related with minimal donor site morbidity. The motor weakness is mild and transient, and the donor site can be closed primarily if the width of the skin island of the flap is less than 8 cm [15, 16]. Although the anterolateral thigh flap has become the workhorse for reconstruction of the skin and soft tissue defects since Song et al. first described it in 1984, are still used very rarely. The basal skin carcinoma, although considered to be the tumor with the low malignancy potential and not significant clinical problem, neglected advanced tumors can be encountered even in the 21th century. There is an entire range of possibilities for the treatment of basal cell lesions, but the therapy of such neglected cases usually demands multidisciplinary surgical and oncological treatment with advanced reconstructive techniques.