<html><head><base href="x-msg://9/"></head><body style="word-wrap: break-word; -webkit-nbsp-mode: space; -webkit-line-break: after-white-space; ">Dear Abhay<div>What a surprise! I do remember; at the HTD we had a steady trickle of lab workers from LSHTM, who jabbed their fingers with virulent L donovani. I did not treat any of them, and none developed systemic disease (unpublished results). I am delighted that the experience did not put you off Leishmania. <div><br></div><div>What you say about thermotherapy is very interesting. I suggested a comparison with intralesional SSG because that is standard treatment. But why not also against the machine? It would be important to refine both techniques first.</div><div><br></div><div>A machine at $5,000 would represent a clear advance. Suitable curettes cost about £7 to £30 in the UK, and don't need a solar panel. </div><div>Best wishes<br><div>
<span class="Apple-style-span" style="border-collapse: separate; color: rgb(0, 0, 0); font-family: Helvetica; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-border-horizontal-spacing: 0px; -webkit-border-vertical-spacing: 0px; -webkit-text-decorations-in-effect: none; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; font-size: medium; "><div><span class="Apple-style-span" style="font-size: 16px; ">Anthony</span></div></span>
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<br><div><div>On 8 Jun 2011, at 13:49, Satoskar, Abhay wrote:</div><br class="Apple-interchange-newline"><blockquote type="cite"><span class="Apple-style-span" style="border-collapse: separate; font-family: Helvetica; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-border-horizontal-spacing: 0px; -webkit-border-vertical-spacing: 0px; -webkit-text-decorations-in-effect: none; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; font-size: medium; "><div ocsi="x"><div style="font-family: Tahoma; direction: ltr; color: rgb(0, 0, 0); font-size: x-small; "><div>Hi Tony:</div><div><font face="tahoma"></font> </div><div><font face="tahoma">You may or may not remember<a></a><span class="Apple-converted-space"> </span>you but I had visited<a></a><span class="Apple-converted-space"> </span>you in 1993 when I was doing my PhD in UK and had a needle stick with Ld.</font></div><div><font face="tahoma">You are right that its critical to achieve sustained temperature<a></a><span class="Apple-converted-space"> </span>deep in the lesion. Unlike other methods, RF<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>therapy involves topical delivery of radiowaves<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>deep into tissues in controlled manner under local anesthesia which allows us to get temperature up to<a></a> 50oC<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>for a sustained period of 1 to 1.5 min. we tried curretage<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>too with some patients but RF<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>therapy is much better with cure rates comparable<a></a><span class="Apple-converted-space"> </span>to SSG<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>injections. The cost of RF<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>therapy is an issue but I was told by the company that they<a></a><a></a><span class="Apple-converted-space"> </span>are working<a></a><span class="Apple-converted-space"> </span>on a machine which will be less than $5,000. This machine is smaller than a laptop and once charged can treat upto<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>80 patients. Also, Thermosurgery<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>is considering developing a machine which could be operated with solar power which would be fantastic for field deployment. I our experience in India so far, most patients are preferring<a></a> RF<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>therapy to SSG<a></a><a></a><a></a><a></a>. we are also finding that the extent of scarring is not determined by the type of treatment but rather by the location of the lesion. Scarring is minimal with good tissue healing when lesion is on vascular<a></a><span class="Apple-converted-space"> </span>part of the body.</font></div><div><font face="tahoma"></font> </div><div><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><font face="tahoma"><a><font face="tahoma">Abhay</font></a></font></font></font></font></font></font></font></font></font></font></font></font></font></font></font></div><div><font face="tahoma"></font> </div><div><font face="tahoma"></font> </div><div><div><font size="2" face="Tahoma"><a></a><font size="2" face="Tahoma"><a></a></font><font size="2" face="Tahoma"><font size="2" face="Tahoma"><a></a></font></font><font size="2" face="Tahoma"><font size="2" face="Tahoma"><font size="2" face="Tahoma"><a></a></font></font></font><font size="2" face="Tahoma"><font size="2" face="Tahoma"><font size="2" face="Tahoma"><font size="2" face="Tahoma">Abhay</font></font></font></font> R Satoskar<a></a><a></a><a></a><a></a><span class="Apple-converted-space"> </span>MD, PhD</font></div><div><font size="2" face="tahoma">Professor</font></div><div><font size="2" face="tahoma">Departments of Pathology and Microbiology</font></div><div><font size="2" face="tahoma">129 Hamilton Hall</font></div><div><font size="2" face="tahoma">1645 Neil Avenue</font></div><div><font size="2" face="tahoma">The Ohio State University</font></div><div><font size="2" face="tahoma">Columbus, Ohio</font></div><div><font size="2" face="tahoma">Tel: 614-366-3417</font></div></div><div dir="ltr"><font color="#000000" size="2" face="Tahoma"></font> </div><div id="divRpF484794" style="direction: ltr; "><hr tabindex="-1"><font color="#000000" size="2" face="Tahoma"><b>From:</b><span class="Apple-converted-space"> </span>Anthony Bryceson [a.bryceson@doctors.org.uk]<br><b>Sent:</b><span class="Apple-converted-space"> </span>Wednesday, June 08, 2011 7:29 AM<br><b>To:</b><span class="Apple-converted-space"> </span>Chang, Kwang-Poo<br><b>Cc:</b><span class="Apple-converted-space"> </span>John David; Satoskar, Abhay;<span class="Apple-converted-space"> </span><a href="mailto:vishwamohan_katoch@yahoo.co.in" style="color: blue; text-decoration: underline; ">vishwamohan_katoch@yahoo.co.in</a>; Raj;<span class="Apple-converted-space"> </span><a href="mailto:leish-l@lineu.icb.usp.br" style="color: blue; text-decoration: underline; ">leish-l@lineu.icb.usp.br</a><br><b>Subject:</b><span class="Apple-converted-space"> </span>Re: [Leish-l] inquiry<br></font><br></div><div></div><div>I have been following the correspondence on heat therapy with interest, having explored it myself in the past.<div><br></div><div>There are two forms of heat therapy. The first uses heat physiologically to promote natural healing, while the second uses heat as form of cautery to burn out the lesion.</div><div><br></div><div>To promote natural healing, heat is applied to the skin at temperatures in the range 37?-40oC. Many species of cutaneous Leishmania do not survive at 37oC and lymphocytes act most efficiently at 40oC. This form of therapy disadvantages the parasite and advantages the host. Temperatures must be accurately applied because the skin burns at 42-45oC, depending on the method and duration of application. The difficulty of this approach is how to achieve accurate delivery and maintain the temperature for many hours per day over many days. Infra-red treatment, as introduced by George Rahim in Baghdad, probably comes into this category; heat from a lamp was applied through a cone, but temperature control was difficult and it was not easy to prevent burns. At the Hospital for Tropical Diseases, London, we developed a method whereby a fine coiled wire was imbedded in a flexible pad made from the stuff that dentists use for making plates. Pads could be custom made, for example to fit the pinna of an ear. A thermistor was incorporated alongside the heating wire in the pad with feedback to the power box so as to maintain an accurate-ish temperature. Nevertheless it was difficult absolutely to prevent burns and patients were effectively tied to the machine for long periods of time. The method worked reasonably well, but we abandoned it as impractical. Eduardo Missoni wrote up some case histories; but we never published anything formally. </div><div><div style="margin-top: 0px; margin-bottom: 4px; margin-right: 0px; margin-left: 0px; font: normal normal normal 12px/normal 'Trebuchet MS'; "><br class="webkit-block-placeholder"></div><p style="margin-top: 0px; margin-bottom: 4px; margin-right: 0px; margin-left: 0px; font: normal normal normal 12px/normal 'Trebuchet MS'; "><i><font class="Apple-style-span" size="4"><span class="Apple-style-span" style="font-size: 16px; "> Missoni E. Heat treatment of cutaneous leishmaniasis. Trop Doct. 1984;14:46</span></font></i>.</p><p style="margin-top: 0px; margin-bottom: 0px; "></p></div><div>WRAIR developed a method whereby water from a water-bath was pumped through an intravenous fluid bag that was applied over the lesion. But I understand that the system did not seem practiacble and was not taken forward. </div><div><br></div><div>Heat cautery burns out the lesions, and the Thermomed instrument that delivers a temperature of 50oC between two electrodes implanted into the lesion comes into this category. It must of course be used with local anaesthetic. I have never used it; but its advantage seems to be that it is painless, and effective, often at a single setting if the lesions is small. John David speaks very highly of it. It is not suitable for all lesions and there can be complications. see </div><div><a href="http://www.crd.york.ac.uk/CMS2Web/ShowRecord.asp?LinkFrom=OAI&ID=32010001498" target="_blank" style="color: blue; text-decoration: underline; ">http://www.crd.york.ac.uk/CMS2Web/ShowRecord.asp?LinkFrom=OAI&ID=32010001498</a> </div><div>for example: "Post treatment wound care is essential, as blistering and secondary infection are the most common adverse effects." With a power box to carry around and electrodes to sterilise, i don't know how useful it may be under field conditions.</div><div><br></div><div>Cryotherapy and simple curettage are other techniques that have been used successfully to destroy leishmanial sores.</div><div><br></div><div>Curettage requires local anaesthetic, but is simple to perform. The curette can be cleaned and safely sterilised by flaming in small steel dish with a few ml of methylated spirit (wait a moment before picking up the curette). Currie published a small study, and was pleased with the results.</div><div><p style="margin-top: 0px; margin-bottom: 4px; margin-right: 0px; margin-left: 0px; font: normal normal normal 12px/normal 'Trebuchet MS'; "><i><font class="Apple-style-span" size="4"><span class="Apple-style-span" style="font-size: 16px; "> Currie MA. Treatment of cutaneous leishmaniasis by curettage. Br Med J (Clin Res Ed). 1983;287:1105-1106.</span></font></i></p></div><div>If I were looking for a simple portable method of treatment in the field I would seriously consider curettage under local anaesthetic. Perhaps there is a dermato-leishmaniac out there who would like to compare curettage with intralesional SSG? But please plan the study carefully - the literature on treatment of CL is littered with uninterpretable publications. It's time we got our act together.</div><div><br></div><div><br></div><div><br></div><div>Anthony Bryceson</div><div><br></div><div><div></div><br><div><div>On 6 Jun 2011, at 17:02, Chang, Kwang-Poo wrote:</div><br class="Apple-interchange-newline"><blockquote type="cite"><div lang="EN-US"><div class="Section1"><div style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><font color="navy" size="2" face="Arial"><span style="font-family: Arial; color: navy; font-size: 10pt; ">Any chance to make it available for additional trials elsewhere ?</span></font></div><p class="MsoNormal" style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><font color="navy" size="2" face="Arial"><span style="font-family: Arial; color: navy; font-size: 10pt; "></span></font> </p><div style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><font color="navy" size="2" face="Arial"><span style="font-family: Arial; color: navy; font-size: 10pt; ">I recall your statement in our conversation about the advantage of this instrument over the heating lamp. That is to maintain the specific elevated temperature uniformly throughout the skin lesion for a sustained period. The 50 C must be the effective temperature that has been experimentally determined. It seems to be a tolerable temperature to human skin ? Dr. Sharma may comment on this medically as a dermatologist ?</span></font></div><p class="MsoNormal" style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><font color="navy" size="2" face="Arial"><span style="font-family: Arial; color: navy; font-size: 10pt; "></span></font> </p><div style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><font color="navy" size="2" face="Arial"><span style="font-family: Arial; color: navy; font-size: 10pt; ">KP</span></font></div><p class="MsoNormal" style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><font color="navy" size="2" face="Arial"><span style="font-family: Arial; color: navy; font-size: 10pt; "></span></font> </p><div><div class="MsoNormal" align="center" style="margin-top: 0in; margin-right: 0in; margin-bottom: 0pt; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; text-align: center; "><font size="3" face="Times New Roman"><span style="font-size: 12pt; "><hr tabindex="-1" align="center" size="2" width="100%"></span></font></div><div style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><b><font size="2" face="Tahoma"><span style="font-family: Tahoma; font-size: 10pt; font-weight: bold; ">From:</span></font></b><font size="2" face="Tahoma"><span style="font-family: Tahoma; font-size: 10pt; "><span class="Apple-converted-space"> </span>John David [mailto:jdavid@hsph.harvard.edu]<span class="Apple-converted-space"> </span><br><b><span style="font-weight: bold; ">Sent:</span></b><span class="Apple-converted-space"> </span>Sunday, June 05, 2011 11:18 PM<br><b><span style="font-weight: bold; ">To:</span></b><span class="Apple-converted-space"> </span>Chang, Kwang-Poo<br><b><span style="font-weight: bold; ">Cc:</span></b><span class="Apple-converted-space"> </span>Sharmanl; Satoskar, Abhay; Raj; Petr Volf;<span class="Apple-converted-space"> </span><a href="mailto:leish-l@lineu.icb.usp.br" style="color: blue; text-decoration: underline; ">leish-l@lineu.icb.usp.br</a>;<span class="Apple-converted-space"> </span><a href="mailto:hgoto@usp.br" style="color: blue; text-decoration: underline; ">hgoto@usp.br</a>;<a href="mailto:elfadil_abass@yahoo.com" style="color: blue; text-decoration: underline; ">elfadil_abass@yahoo.com</a>;<span class="Apple-converted-space"> </span><a href="mailto:vishwamohan_katoch@yahoo.co.in" style="color: blue; text-decoration: underline; ">vishwamohan_katoch@yahoo.co.in</a><br><b><span style="font-weight: bold; ">Subject:</span></b><span class="Apple-converted-space"> </span>Re: [Leish-l] inquiry</span></font></div></div><p class="MsoNormal" style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><font size="3" face="Times New Roman"><span style="font-size: 12pt; "></span></font> </p><div style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><font size="3" face="Times New Roman"><span style="font-size: 12pt; ">The Themomed instrument shown below can produce accurate 50 degrees C plus or minus 0.2 degrees temperature by radio wave.</span></font></div><div><div style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><font size="3" face="Times New Roman"><span style="font-size: 12pt; ">from Themorsurgery Technologies. Picture below.</span></font></div></div><div><div style="margin-top: 0in; margin-bottom: 0pt; margin-right: 0in; margin-left: 0in; font-family: 'Times New Roman'; font-size: 12pt; "><font size="3" face="Times New Roman"><span style="font-size: 12pt; ">Two papers of a trial in Brazil and one in Afghanistan on CL below.</span></font></div></div></div></div>_______________________________________________<br>Leish-l mailing list<br><a href="mailto:Leish-l@lineu.icb.usp.br" style="color: blue; text-decoration: underline; ">Leish-l@lineu.icb.usp.br</a><br><a href="http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/leish-l" style="color: blue; text-decoration: underline; ">http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/leish-l</a><br></blockquote></div><br></div></div></div></div></span><br class="Apple-interchange-newline"></blockquote></div><br></div></div></body></html>