Faculty Bibliography

BACKGROUND AND OBJECTIVE: This case demonstrates, for the first time, the use of in vivo confocal imaging to assess the efficacy of laser treatment of a skin lesion with a vascular component. STUDY DESIGN/PATIENT AND METHOD: A patient with lesions of sebaceous gland hyperplasia was histologically imaged in vivo before and after treatment with a 585 nm pulse dye laser (PDL) by using a near-infrared, confocal reflectance microscope. Hyperplastic sebaceous ducts and sebaceous glands were seen with high resolution in vivo. Prominent dermal vasculature was viewed as well as its selective targeting by PDL. CONCLUSION: Our results confirm the previously reported successful treatment of sebaceous gland hyperplasia with the 585 nm PDL

Near-infrared confocal reflectance microscopy (CM) is a high-resolution: non-invasive imaging technique with promising future in dermatology. A pustular lesion from a 35-year-old male with a known history of folliculitis was non-invasively viewed with CM and later biopsied. Optical sections were correlated with routine histology. This optical technique allows us to view non-invasively transverse skin sections to a controlled depth in real time. In the CM images, tissue can be visualize with cellular and subcellular detail as shown by imaging infiltrating neutrophils (PMNs) within the subcorneal pustule of a superficial folliculitis in vivo

BACKGROUND: Allergic contact dermatitis (ACD) is a common and often challenging clinical problem. In vivo near-infrared confocal reflectance microscopy (CM) is a new vital microscopy technique. OBJECTIVE: CM was used to evaluate acute ACD. METHODS: Patch testing by means of Finn Chambers technique was performed in 5 subjects to induce an acute allergic skin reaction. Noninvasive CM images from normal and eczematous skin were sequentially recorded before and after removal of the Finn Chambers. RESULTS: The epidermis and papillary dermis were clearly seen in high resolution. Retention of nuclei in stratum corneum, epidermal edema with microvesicle formation, and transepidermal migration of inflammatory cells were observed in vivo. Isolated dendritic cells were present in the ACD sites of 2 subjects, with morphology, size, and location consistent with Langerhans cells. Dermal vasodilation was observed as well. CONCLUSION: CM is a useful tool to study ACD and may be able to track Langerhans cell activation

OBJECTIVES: To assess the potential of a near-infrared confocal laser scanning microscope (CLSM) for imaging bladder tissue in vivo. METHODS: Confocal images of the exposed bladder of male Sprague-Dawley rats were obtained with a CLSM. To minimize tissue motion, the bladder was placed in light contact under an objective lens housing, and the top surface was lightly flattened with a coverslip. Images were obtained from the outer and inner layers of the bladder wall with a lateral resolution of 0.5 to 1 microm and an axial resolution (section thickness) of 3 to 5 microm. The confocal images were later correlated with routine histologic studies. RESULTS: The CLSM allows imaging of the urothelium, the superficial and deep portions of the lamina propria, the muscularis propria, and the serosa of the bladder wall in vivo. Urothelial cells, collagen bundles and fibers, muscle, and circulating blood cells in capillaries and larger blood vessels are easily visualized. The confocal images correlated well with the histologic studies. CONCLUSIONS: Confocal microscopy allows real-time, high-resolution, high-contrast imaging of cellular and structural morphologic features to a maximal depth of 300 microm within the bladder wall in vivo. Artifacts caused by tissue motion can be minimized with a bladder-objective lens contact housing

OBJECTIVE: To review the effectiveness of a perioperative management protocol and our experience with a large population of patients with von Willebrand disease (vWD) who require adenotonsillar surgery (T&A). DESIGN: A retrospective review of the medical records of all patients having the diagnosis of vWD who underwent T&A between January 1, 1992, and July 31, 1996. SETTING: A tertiary care, university-based children's hospital. INTERVENTIONS: Patients having a preoperative diagnosis of vWD received a single intravenous dose of desmopressin acetate, 0.3 pg/kg, approximately 20 minutes before the induction of anesthesia. Beginning January 15, 1994, a standard management protocol involving the postoperative administration of fluids and electrolytes was followed. MAIN OUTCOME MEASURES: Operative blood loss and the incidence of postoperative bleeding and of hyponatremia. RESULTS: Of approximately 4800 patients who underwent T&A during the study period, 69 patients had a diagnosis of vWD. All 67 patients identified preoperatively received desmopressin; 2 were identified by postoperative workup as a result of excessive surgical bleeding. Minimal immediate postoperative bleeding was noted in 7 patients (10%), but none required intervention. Delayed bleeding occurred in 9 patients (13%); all were readmitted to the hospital for observation, 4 (6%) requiring operative cauterization. Substantial postoperative hyponatremia occurred in 3 patients, and 1 patient had seizure activity. Symptomatic hyponatremia has been avoided since a protocol of fluid and electrolyte administration was instituted. CONCLUSIONS: Although T&A can be performed safely in patients with vWD, it is not without an increased risk of postoperative hemorrhage. The administration of desmopressin has been reported to reduce the risk of bleeding, but it is not without risk. A protocol for fluid and electrolyte management is recommended

OBJECTIVE: To reconcile conflicting reports concerning the incidence of otorrhea in children with tympanostomy tubes who swim without ear protection. STUDY SELECTION: Articles were identified by MEDLINE search, Current Contents, and references from review articles, textbook chapters, and retrieved reports. Controlled trials of water precautions following tympanostomy tube placement were selected by independent observers and scored on 10 measures of study validity. Five English-language articles met all inclusion criteria. DATA EXTRACTION: Data were abstracted for an endpoint of otorrhea following swimming without ear protection with a minimum follow-up of 6 weeks. DATA SYNTHESIS: Pooled analysis of 619 children revealed a rate difference of -5.04 (95% confidence interval [CI], -11.62 to 1.54). No significant difference in the incidence of otorrhea was noted between patients who swam without ear protection and nonswimmers. CONCLUSION: There is no increase in incidence of otorrhea in children who swim without ear protection compared with children who do not swim following tympanostomy tube placement

Inferior colliculus (IC) slice cultures from postnatal (P) day 6-8 gerbils exhibit axonal regeneration across a lesion site, and these regrowing processes can form synapses. To determine whether regenerative capacity is lost in older tissue, as occurs in vivo, slices from P12-21-day animals were grown under similar conditions. While these cultures displayed a near complete loss of neurons over 6 days in vitro, glutamate receptor antagonists (AP5 and/or CNQX) significantly enhanced survival, particularly at P12-15. In contrast, several growth factors or high potassium did not improve neuron survival. Therefore, axonal regeneration was assessed following complete transection of the commissure in AP5/CNQX-treated IC cultures from P12 animals. Neurofilament staining revealed that transected commissural axons survived for 6 days in vitro, but only a few processes crossed the lesion site and these axons did not extend into the contralateral lobe. In contrast, there was robust axonal sprouting and growth within one lobe of the IC, remote from the lesion site. When P6 and P12 tissue was explanted onto a coated substrate, the P6 axons grew onto the substrate, but the P12 axons were seemingly prevented from reaching the substrate by a veil of nonneuronal cells. Coculture of the IC and one of its afferent populations, the lateral superior olive, provided a similar finding, indicating that failure to regenerate was a general property at the age examined. These data show that neuron survival is not sufficient to permit axon regeneration at P12, and suggest that P12 lesion sites manufacture a prohibitive substrate since process outgrowth is blocked specifically at the commissure transection

The lateral superior olive (LSO) is a primary site of binaural convergence that responds selectively to changes in interaural level difference (ILD) by integrating ipsilateral excitatory and contralateral inhibitory inputs. The circuit matures during the first three postnatal weeks, undergoing several structural and functional changes that are influenced by afferent activity. Therefore modulation of synaptic activity by neuromodulators may participate in the maturation of this circuit. The present study describes robust effects of serotonin (5-HT) on LSO synaptic function. Using whole cell voltage-clamp recording from gerbil LSO neurons (postnatal days 6-13) in an in vitro slice preparation, we have identified several distinct forms of serotonergic modulation of spontaneous and evoked synaptic transmission. First, 1-2 min application of 5-HT (100 microM) activated prolonged bursts of spontaneous inhibitory postsynaptic currents (IPSCs). However, there was an age-dependent decline, such that this effect rarely was observed beyond postnatal day 8. 5-HT apparently increased the excitability of inhibitory afferents, because 5-HT-induced IPSCs were blocked by tetrodotoxin. A second effect of 5-HT was to depress rapidly and profoundly the amplitude of electrically evoked excitatory postsynaptic currents (EPSCs). In contrast, 5-HT also depressed evoked IPSCs but to a significantly lesser degree. The receptor subtypes mediating these effects were examined using specific 5-HT agonists and antagonists. A 5-HT1 agonist, 5-carboxamidotryptamine, produced EPSC depression but did not induce spontaneous IPSCs. A 5-HT2 agonist, alpha-Me-5-HT, reproduced all the observed effects of 5-HT (PSC depression as well as induction of spontaneous IPSCs), whereas a 5-HT2 antagonist, ketanserin, blocked the induction of spontaneous IPSCs. Therefore induction of spontaneous IPSCs is mediated by 5-HT2 receptors, whereas both 5-HT1 and 5-HT2 receptor types contribute to PSC depression. Serotonergic modulation of LSO synapses may have consequences for both developmental plasticity and auditory function. Serotonergic induction of IPSCs was observed primarily in young animals and thus may represent a mechanism for amplifying the activity of inhibitory synapses in LSO during a period of use-dependent plasticity in postnatal development. PSC depression, which preferentially affects excitation, is a potential mechanism for modulation of ILD tuning