BACKGROUND:Fluorescence imaging is an attractive diagnostic technique for skin tumour demarcation with potential to move to clinical use. Bispectral fluorescence imaging combines skin autofluorescence with delta-aminolaevulinic acid-induced fluorescence. To evaluate the technique, fluorescence data must be compared with the histopathological extent of the tumour, which is the purpose of the current study.OBJECTIVES:To investigate the agreement between bispectral fluorescence images and the histopathological tumour boundary of ill-defined basal cell carcinomas (BCCs). After fluorescence imaging the tumours were removed using Mohs micrographic surgery (MMS) to obtain histopathological maps of the tumour boundaries.METHODS:Twelve patients with aggressive BCC of mean diameter 16 mm (range 5-32) in the face were included in the study. The patients were subjected to bispectral fluorescence imaging within the 2 months prior to MMS. The fluorescence images and histopathological maps were aligned using image warping.RESULTS:Five patients (42%) showed good agreement with the histopathological mapping and the remaining seven patients (58%) showed partial agreement. Bispectral investigation combining autofluorescence with protoporphyrin IX (PpIX) fluorescence generally yielded better agreement with the histopathological boundaries of the tumours compared with using only the PpIX fluorescence.CONCLUSIONS:In this preliminary study the fluorescence has been compared with the histopathological tumour boundaries. The result implies that the technique can be applied as a useful tool for indicating tumour boundary of aggressive BCCs. Further refinement is needed to be able to indicate the exact tumour border.

Fluorescence imaging has been shown to be a potential complement to visual inspection for demarcation of basal cell carcinoma (BCC), which is the most common type of skin cancer. Earlier studies have shown promising results when combining autofluorescence with protoporphyrin IX (Pp IX) fluorescence, induced by application of delta-5-aminolaevulinic acid (ALA). In this work, we have tried to further improve the ability of this technique to discriminate between areas of tumor and normal skin by implementing texture analysis and Fisher linear discrimination (FLD) on bispectral fluorescence data of BCCs located on the face. Classification maps of the lesions have been obtained from histopathologic mapping of the excised tumors. The contrast feature obtained from co-occurrence matrices was found to provide useful information, particularly for the ALA-induced Pp IX fluorescence data. Moreover, the neighborhood average features of both autofluorescence and Pp IX fluorescence were preferentially included in the analysis. The algorithm was trained by using a training set of images with good agreement with histopathology, which improved the discriminability of the validation set. In addition, cross validation of the training set showed good discriminability. Our results imply that FLD and texture analysis are preferential for correlation between bispectral fluorescence images and the histopathologic extension of the tumors.

Genomes of human papillomaviruses (HPV) are common in biopsies from non-melanoma skin cancers but are also found on healthy skin and it is possible that HPV positivity in tumor biopsies by PCR may merely reflect contamination of the lesion surface. To investigate this issue, 229 immunocompetent patients were tested for HPV DNA in swab samples collected on top of skin tumors and in biopsies of the same tumors, obtained after stripping with tape to remove superficial layers. HPV DNA was detected on top of 69% (159 of 229) of the lesions, and in 12% (28 of 229) of the stripped biopsies (p<0.001). The difference was seen for all four types of tumors studied. Seborrheic keratosis had 79% (34 of 43) HPV positivity on top of lesions versus 19% (eight of 43) in biopsies; actinic keratosis had 83% (38 of 46) HPV positivity on top versus 11% (five of 46) in biopsies; basal cell carcinoma had 63% (69 of 109) on top versus 8% (nine of 109) in biopsies and squamous cell carcinoma had 58% (18 of 31) on top versus 19% (six of 31) in biopsies. HPV DNA is common in superficial layers of lesions, but is not necessarily present throughout tumors.

BACKGROUND:Although photodynamic therapy (PDT) is becoming an important treatment method for skin lesions such as actinic keratosis (AK) and superficial basal cell carcinoma, there are still discussions about which fluence rate and light dose are preferable. Recent studies in rodents have shown that a low fluence rate is preferable due to depletion of oxygen at high fluence rates. However, these results have not yet been verified in humans.OBJECTIVES:The objective was to investigate the impact of fluence rate and spectral range on primary treatment outcome and bleaching rate in AK using aminolaevulinic acid PDT. In addition, the pain experienced by the patients has been monitored during treatment.PATIENTS/METHODS:Thirty-seven patients (mean age 71 years) with AK located on the head, neck and upper chest were treated with PDT, randomly allocated to four groups: two groups with narrow filter (580-650 nm) and fluence rates of 30 or 45 mW cm(-2), and two groups with broad filter (580-690 nm) and fluence rates of 50 or 75 mW cm(-2). The total cumulative light dose was 100 J cm(-2) in all treatments. Photobleaching was monitored by fluorescence imaging, and pain experienced by the patients was registered by using a visual analogue scale graded from 0 (no pain) to 10 (unbearable pain). The primary treatment outcome was evaluated at a follow-up visit after 7 weeks.RESULTS:Our data showed a significant correlation between fluence rate and initial treatment outcome, where lower fluence rate resulted in favourable treatment response. Moreover, the photobleaching dose (1/e) was found to be related to fluence rate, ranging from 4.5 +/- 1.0 J cm(-2) at 30 mW cm(-2), to 7.3 +/- 0.7 J cm(-2) at 75 mW cm(-2), indicating higher oxygen levels in tissue at lower fluence rates. After a cumulative light dose of 40 J cm(-2) no further photobleaching took place, implying that higher doses are excessive. No significant difference in pain experienced by the patients during PDT was observed in varying the fluence rate from 30 to 75 mW cm(-2). However, the pain was found to be most intense up to a cumulative light dose of 20 J cm(-2).CONCLUSIONS:Our results imply that the photobleaching rate and primary treatment outcome are dependent on fluence rate, and that a low fluence rate (30 mW cm(-2)) seems preferable when performing PDT of AK using noncoherent light sources.

Fluorescence imaging has shown a potential for demarcation of basal cell carcinoma (BCC), which is the most common type of skin cancer. The technique is based on imaging the fluorescence from protoporphyrin IX (Pp IX), after application of delta-5-aminolevulinic acid (ALA). One limitation with the technique is that it is sensitive for undesired local intensity variations. But it has been shown that by combining autofluorescence, i.e. fluorescence without any externally applied photosensitiser, and the Pp IX fluorescence, higher contrast between tumour and normal skin can be obtained. This has earlier been reported using a laser-based technique allowing for simultaneous recording of autofluorescence and Pp IX fluorescence. In this work we present a method, using a simple set up for multispectral imaging assisted by computerised image warping. The set up was evaluated investigating 9 patients with histologically verified BCC located in the face. Z-images, defined as the ratio between the autolluorescence and the Pp IX fluorescence images, were obtained and compared to the clinically marked tumour borders. Agreement with the tumour border was found in 8 out of the 9 patients. These results imply that multispectral fluorescence imaging is a potential diagnostic tool for demarcation of BCC.

BACKGROUND:The aim of our study was to test the feasibility of culturing Helicobacter pylori directly from biopsies aimed for rapid urease test in routine clinical practice. MATERIALS AND METHODS:In 260 consecutive patients referred for gastroscopy because of dyspepsia one antral biopsy was routinely used for our "in house" rapid urease test (RUT). Positive biopsies were placed in a transport medium and sent to the laboratory. The biopsies were cultured and incubated at 37 degrees C for 5-7 days. H. pylori was identified and routinely tested for antimicrobial resistance by using the E-test. RESULTS:In 118 out of 260 patients (45%) the urease test turned positive and the growth of H. pylori was sufficient to allow testing of antimicrobial resistance. CONCLUSION:H. pylori could be cultured from almost all positive RUT specimens. A liquid RUT is thus more suitable for culture, saving additional biopsies.

Photodynamic therapy has become an interesting alternative to conventional therapy for basal cell carcinomas. Delta-aminolevulinic acid is a precursor in the biosynthesis of protoporphyrin IX that accumulates to a large extent in tumour tissue. We have compared in vivo protoporphyrin IX fluorescence with the extent of basal cell carcinomas on the face, trunk and thigh determined by histological mapping in 30 lesions in 22 patients. A new non-laser based set-up was used to record the fluorescence images. Delta-aminolevulinic acid was applied for 4 h inducing high concentrations of protoporphyrin IX. Routine vertical histological sections and Mohs micrographic surgery were used to map the extent of the tumours. In 50% of lesions we found a good correlation between the fluorescence imaging and histological mapping. In 23% the correlation was partial. In the other lesions we found no correlation at all. This method may be used to delineate basal cell carcinomas more accurately than current methods.

Mohs' micrographic surgery of facial basal cell carcinoma ensures a high cure rate with maximal preservation of healthy tissue. Using precise margin control, this procedure allows complete examination of all margins of tissue removed. Due to the insufficient facilities for Mohs' micrographic surgery in Sweden, only the most aggressive tumours are referred for this procedure, which could increase the risk of recurrences. We have operated on 228 basal cell carcinomas, 87 primary and 141 recurrent tumours, over the period 1983 to 1992. The tumours were located on the face and all patients were followed for 5 years after surgery. The recurrence rate was 6.5% for primary and 10% for recurrent basal cell carcinomas. After 12 months the functional and cosmetic results were evaluated, showing good or satisfactory results in 93% of cases. Mohs' surgery is an underused but still efficacious technique in Sweden and should be recommended to other centres.

A pair of degenerate PCR primers (FAP59/64) was designed from two relatively conserved regions of the L1 open reading frame of most human papillomaviruses (HPV), The size of the generated amplicon was about 480 bp, PCR using these primers was found capable of amplifying DNA from 87% (65/75) of the HPV types tested, its sensitivity being 1-10 copies for HPV-5, -20 and -30 clones, HPV was found in 63% (5/8) of tumour samples and in 63% (5/8) of normal skin biopsies from patients with various cutaneous tumours, HPV-5, HPV-8, HPV-12, HPVvs20-4 and six putatively novel HPV types were identified, No correlation was found to exist between specific HPV and tumour types, Skin surface swab samples from one or more sites on three of four healthy volunteers were found to contain HPV, types 12 and 49 being identified, as well as eight novel HPV types, two of which were also found among the patients, In all, HPV was detected in 75% (9/12) of those tested, five HPV types and 12 novel candidate types being identified, and 37% (7/19) of HPV-positive samples were found to manifest more than one HPV type, All the HPV detected manifested high degrees of nucleotide sequence similarity with HPV types associated with skin lesions and epidermodysplasia verruciformis, The overall HPV finding in the skin samples was 50% (20/40) using the FAP primers as compared to 18% (7/40) using another PCR test designed for skin types, The results thus suggest the new method to be sensitive and generally applicable for detecting cutaneous HPV.

AIM:Primary resistance of H pylori strains to antimicrobials has direct therapeutical implications. For this reason we studied the prevalence of primary resistance of H pylori of Sweden, in a regional setting. MATERIAL AND METHODS:A total of 244 patients referred to our endoscopy unit have been evaluated prospectively for the occurrence of H pylori. Helicobacter pylori infection was established by a positive rapid urease test on an antral biopsy. If positive the biopsy specimen was transferred to a transportmedium for culture on a Skirrow medium. Antimicrobial resistance was evaluated by the E-test. RESULTS:In 109 patients H pylori infection was seen and in all of them the culture was positive. No resistance was seen for amoxycillin and tetracycline. The resistance against metronidazole was 40.3% and and against clarithromycin it was 2.8%. For metronidazole there was a significantly higher resistance seen in women compared to men (53.3% vs 31.2%; p < 0.001). CONCLUSIONS:Primary resistance to metronidazole was higher than expected and over average in Europe. The resistance for clarithromycin is still rare. Further monitoring is mandatory to detect changes in the community.

Mohs' micrographic surgery (MMS) is the recommended treatment for large basal cell carcinomas (BCCs) of the nose. This 5-year follow-up study attempts to evaluate whether curettage-cryosurgery (CC) could be an alternative therapy in a country where optimal resources for MMS are lacking. All patients with a primary nasal or perinasal BCC, 10 mm or larger in diameter, were assessed at a skin tumour clinic. Sixty-one BCCs of non-morphoeiform type were treated with CC. Most of the tumour was removed by careful curettage with different sized curettes. The tumour area was then frozen with liquid nitrogen in a double freeze-thaw cycle. Fifty patients were followed for at least 5 years with only one recurrence. The cosmetic result was good or acceptable in all patients. A thorough curettage followed by cryosurgery could be a safe and inexpensive alternative therapy even for large primary non-morphoeiform BCCs of the nose.

Background.This double‐blind, randomized study evaluated the efficacy of dual and triple therapies including ranitidine for treatment of Helicobacter pylori infection.Materials and Methods.Dyspeptic patients (n = 105) with a positive rapid urease test formed the intention‐to‐treat population (ITT). All patients were assigned to 14 days treatment with ranitidine 300 mg b.i.d and clarithromycin 750 mg b.i.d. Group A (n = 53) also received a placebo twice daily, while group B (n = 52) received lymecycline 300 mg b.i.d. Treatment with ranitidine, 150 mg b.i.d, was continued for an additional 30 days. H. pylori infection was verified by culture. Twelve weeks after antibiotic treatment, H. pylori status was investigated by culture and 14C‐urea breath test (UBT). The per‐protocol (PP) group consisted of 73 patients (A, n = 38; B, n = 35).Results.Cure rates were 87% (95% C.I. = 72% to 94%) vs. 72% (95% C.I. = 58% to 83%) in the ITT‐group and 89% (95% C.I. = 73% to 97%) vs. 87% (95% C.I. = 72% to 96%) in the PP‐population (culture and UBT) when triple and dual therapies were compared. In all patients who were not cured, clarithromycin resistance of H. pylori was acquired. Side effects were experienced by 54% of patients.Conclusions.The difference in efficacy between the two treatment regimens was not significant. However, the cure rates in this study are comparable to combination treatments with omeprazole. Treatment failures were due to acquired clarithromycin resistance.

Human papillomavirus (HPV) type 16 is casually involved in the pathogenesis of anogenital cancer and has also been demonstrated in some patients with Bowen's disease (BD) on the fingers. From two women with HPV 16 in BD on the fingers, and in archival samples from genital dysplasia, collected as long as 26 years ago, the non-coding region of the virus was amplified by the polymerase chain reaction and sequenced. The HPV 16 DNA sequences found in the finger lesions and in the genital archival samples showed no diversities within single patients. Compared with an HPV 16R reference sequence, one patient showed a unique T nucleotide at position 78, whereas the other patient exhibited T and A nucleotides at positions 7193 and 7521, respectively. In one of the patients, the same strain of HPV 16 was found in a digital tumour 26 years after its clearance from the genital tract. DNA sequence analysis indicated patient-specific HPV 16 strains. Auto-inoculation from the genital tract was favoured as a plausible explanation of why HPV 16 caused BD on the fingers.

Ropivacaine is a new type of long-acting local anaesthetic of less systemic toxicity than bupivacaine. The objective of this double-blind study was to compare the efficacy and safety of ropivacaine 0.5% and mepivacaine 1% for infiltration anaesthesia in dermatologic surgery. Sixty out-patients aged 18–65 years, scheduled for excision of a benign naevus on the back, were randomly assigned to infiltration anaesthesia with either ropivacaine or mepivacaine. Both agents had a fast onset, and provided reliable anaesthesia and painfree surgery which could be carried out without the use of vasoconstrictive adjuncts or diathermy. Ropivacaine resulted in a longer duration of analgesia than mepivacaine, and both treatments were well tolerated.

The completeness of vagal denervation in determining the long-term outcome of patients with duodenal ulcer disease after proximal gastric vagotomy (PGV) was studied by examining the relationship between the postoperative acid secretory response to sham feeding ('chew and spit' technique) and the subsequent ulcer recurrence rate during a mean follow-up of 7.5 (range 5-15) years. The cumulative recurrence rate of 98 patients analysed prospectively was 11 per cent. Of 22 patients who had incomplete vagotomy as suggested by the sham feeding response, five had a later relapse. This compares with only an 8 per cent relapse rate among those with a secretory response suggesting complete vagotomy. Four patients suffered from a relapse moire than 5 years after operation but none had undergone incomplete vagotomy. However, in seven patients with an early postoperative relapse (within 5 years) five had had incomplete vagal denervation (P < 0.05). In this latter group the median time elapsed from surgery until the first recurrence was only 1 year. It is concluded that the early postoperative acid secretory response to a sham feeding stimulus is clinically useful as it allows prediction of the risk of early relapse after PGV. This test may be helpful fbr the validation of new techniques of vagotomy.