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  • Selected Abstracts

    Teamwork and patient safety in dynamic domains of healthcare: a review of the literature

    Aims/Background: This review examines current research on teamwork in highly dynamic domains of healthcare such as operating rooms, intensive care, emergency medicine, or trauma and resuscitation teams with a focus on aspects relevant to the quality and safety of patient care. Results: Evidence from three main areas of research supports the relationship between teamwork and patient safety: (1) Studies investigating the factors contributing to critical incidents and adverse events have shown that teamwork plays an important role in the causation and prevention of adverse events. (2) Research focusing on healthcare providers' perceptions of teamwork demonstrated that (a) staff's perceptions of teamwork and attitudes toward safety-relevant team behavior were related to the quality and safety of patient care and (b) perceptions of teamwork and leadership style are associated with staff well-being, which may impact clinician' ability to provide safe patient care. (3) Observational studies on teamwork behaviors related to high clinical performance have identified patterns of communication, coordination, and leadership that support effective teamwork. Conclusion: In recent years, research using diverse methodological approaches has led to significant progress in team research in healthcare. The challenge for future research is to further develop and validate instruments for team performance assessment and to develop sound theoretical models of team performance in dynamic medical domains integrating evidence from all three areas of team research identified in this review. This will help to improve team training efforts and aid the design of clinical work systems supporting effective teamwork and safe patient care. [source]

    Artificial and bioartificial support systems for liver failure: a Cochrane Hepato-Biliary Group Protocol

    Jianping Liu
    Abstract: Aims/Background: Liver support systems may bridge patients to liver transplantation or recovery from liver failure. This review is to evaluate the beneficial and harmful effects of artificial and bioartificial support systems for acute and acute-on-chronic liver failure. Data Sources: Randomized trials on any support system versus standard medical therapy will be included irrespective of publication status or language. Non-randomized studies are included in explorative analyses. Trials will be identified through bibliographies, correspondence with original investigators, and electronic searches (Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Controlled Trials Register, MEDLINE, EMBASE, and The Chinese Biomedical Database). Methods of the review: The extracted data will include characteristics of trials, patients, interventions, and all outcome measures. Methodological quality will be assessed by the randomization, follow up, and blinding. The RevMan and STATA will be used for statistical analyses. Sources of heterogeneity and methodological quality in the assessment of the primary outcome will be explored by sensitivity analyses and meta-regression. [source]

    Leptin deficiency reduces but does not eliminate the development of hepatic fibrosis in mice infected with Schistosoma mansoni

    James J. Potter
    Abstract: Aims/Background: Leptin, a product of the obese (ob) gene, was demonstrated previously in activated hepatic collagen-producing stellate cells, but not in quiescent retinol-storing stellate cells. The role of leptin in fibrogenesis is unknown. This study investigated the possible influence of leptin in the pathogenesis of fibrosis by determination of the amount of fibrosis produced by Schistosoma mansoni infection in leptin deficient male ob/ob mice as compared to control mice. Methods: The mice were infected percutaneously with cercaria of Schistosoma mansoni and the amount of liver fibrosis determined 12 weeks after infection. The amount of hepatic collagen deposited was quantified by morphometric analysis of liver sections stained with sirius red and by hydroxyproline content. Results: The amount of histologically detectable fibrosis was greater in the infected controls than in the infected ob/ob mice. In the infected control mice, but not in the ob/ob mice, the fibrosis surrounding the granuloma was broad and extended beyond the portal tracts into the lobule with the formation of fibrous septa. Conclusions: This study shows that leptin is a potentiating, but not an essential factor, for the development of hepatic fibrosis, because leptin deficiency reduces but does not prevent the development of hepatic fibrosis. [source]

    A novel role of alkaline phosphatase in protection from immunological liver injury in mice

    Qiang Xu
    Abstract:Aims/Background: Little is known about the role of alkaline phosphatase (AP) in liver diseases, except for its elevation in jaundice or cholestasis. Its substrate, endotoxin, is usually elevated in patients as well as animals with liver damage. This study aimed to provide evidence for its new role as protection against immunological liver damage. Methods: Liver injury was induced in mice by delayed-type hypersensitivity to picryl chloride. AP activity was measured using a commercial kit. Results: In acute liver injury, a significant decrease in AP activity in serum was observed but there was an increase in liver tissue. Single administration of cyclophosphamide before sensitization with picryl chloride exacerbated the liver injury, with more serious AP changes, while consecutive use after the sensitization alleviated the injury with a recovery from the changes. When liver injury proceeded for 1 week, both serum and liver showed decreased AP activity. Lipopolysaccharide facilitated alanine transaminase release from levamisole-pretreated but not non-treated hepatocytes from naive mice. However, the release was confirmed from liver slices of mice with liver injury proceeding for 1 week, even without levamisole pretreatment. Conclusion: The development of liver injury may lead to a dysfunction in AP synthesis and release. Levamisole may make normal hepatocytes, like the hepatocytes from liver-injured mice, highly sensitive to lipopolysaccharide through inhibiting AP synthesis. The findings obtained in this study suggest that AP may contribute to protection from injury by a mechanism involving neutralization of endotoxin. [source]

    Neuronal nitric oxide synthase immunoreactivity in the guinea-pig liver: distribution and colocalization with neuropeptide Y and calcitonin gene-related peptide

    Francisco J. Esteban
    Abstract:Aims/Background: The innervation pattern of the guinea-pig liver is similar to that of the human liver. However, many aspects of the distribution of the neuronal isoform of the enzyme nitric oxide synthase (nNOS) in the guinea-pig liver and its colocalization with neuropeptides remain to be elucidated. Methods: The distribution of nNOS was studied in fixed guinea-pig liver by light microscopic immunohistochemistry. Confocal analysis was used to determine its colocalization with neuropeptide Y (NPY) or calcitonin gene-related peptide (CGRP). Results: nNOS-immunoreactive (nNOS-IR) nerves were observed in relation to hilar and interlobar vessels and in Glisson's capsule. A few nNOS-IR ganglia were observed in the extrahepatic bile duct and close to the interlobar portal triads. In addition, nNOS-IR fibers were located in the interlobular portal triads and pervading the parenchyma. Moreover, nNOS-IR nerves were demonstrated for the first time in the larger central veins and in the hepatic vein. nNOS-NPY and nNOS-CGRP colocalizations were detected in the fibromuscular layer of the bile duct and periductal plexus, respectively. Conclusions: These results support the phylogenetic conservation of the nNOS-IR hepatic innervation and its possible contribution to the regulation of hepatic blood flow and certain hepatic functions. [source]

    Red blood cells attenuate sinusoidal endothelial cell injury by scavenging xanthine oxidase-dependent hydrogen peroxide in hyperoxic perfused rat liver

    Satoru Motoyama
    Abstract:Aims/Background: Rat liver perfused with an oxygenated buffered solution alone results in degenerative changes even when the perfusion flow is accelerated to give a sufficient oxygen supply. On the other hand, perfusion media supplemented with red blood cells (RBCs) preserve the viability of the liver. The present study was conducted to clarify how RBCs protect the isolated perfused liver. Methods: The liver was perfused with and without RBCs in a perfusate equilibrated with supra-physiological oxygen tension at regulated inflow pressures, and controlled hepatic oxygen consumption. We examined alanine aminotransferase and purine nucleoside phosphorylase activity in the perfusate as specific markers of liver cells injury. Hydrogen peroxide (H2O2) production and morphological changes were determined using cerium electron microscopy. Apoptosis was detected by measuring CPP 32 protease activity and using TdT-mediated dUTP-digoxigenin nick end-labeling. Results: When the liver was perfused with RBC-free buffer, H2O2 production and consequent injury progressing to apoptosis were initiated in the sinusoidal endothelial cells (SECs). After SECs were injured, H2O2 appeared in the hepatocytes. H2O2 production and associated degenerative changes were attenuated both morphologically and enzymatically by the addition of RBCs, a specific xanthine oxidase (XOD) inhibitor and the H2O2 radical scavenger, catalase. Conclusions: In the liver perfused with RBC-free buffer, H2O2 production and consequent injury were initiated in SECs. RBCs attenuate liver injury by scavenging XOD-dependent H2O2. [source]

    Continuous infusion of prostaglandin E1 via the superior mesenteric artery can prevent hepatic injury in hepatic artery interruption through passive portal oxygenation

    Tsutomu Sato
    Abstract:Aims/Background: Hepatic artery interruption (HAI) causes severe ischemic liver damage, especially following hepatopancreatobiliary surgery. In order to inhibit a decrease in oxygen delivery after HAI, continuous infusion of PGE1 via the superior mesenteric artery (SMA) was administered in pigs and changes in hepatic blood flow and oxygen delivery were investigated. Furthermore, its effectiveness in the prevention of liver injury was evaluated by histology and serum enzyme levels. Methods: Animals were subjected to HAI without PGE1 infusion (control group n=6) and to continuous infusion of PGE1 (0.02 ,g/kg/min) into the SMA (PGE1 group n=6). Results and Conclusion: PGE1 infusion via the SMA not only increased the portal blood flow but also elevated the oxygen content of the portal blood. The reduction in oxygen delivery to the liver was 50% in the control group, and only 13% in the PGE1 group. Serum aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) levels 24 h after HAI in the control group were 3415±1283 IU/L and 9839±2959 respectively while in the PGE1 group they were 939±426 IU/L and 5510±1545 IU/L respectively. Histological examination showed massive necrosis in the control group at 72 h but only focal liver cell necrosis in the PGE1 group. Based on this finding and the fact that this treatment can be performed easily and safely, continuous infusion of PGE1 via the SMA may be a useful intervention to prevent severe liver damage after hepatic artery interruption. [source]

    Diode laser photocoagulation of choroidal neovascularization associated with retinal pigment epithelial detachment

    Francisco Gomez-Ulla
    ABSTRACT. Aims/Background: Association of choroidal neovascularization with pigment epithelial detachment is not an uncommon feature. Since this condition usually has a poor visual outcome, new treatments should be developed. Methods: We studied the anatomical and visual results of 11 eyes with this association as a manifestation of an Exudative Age Related Macular Degeneration which were treated with diode laser photocoagulation guided by indocyanine green angiography. The average follow up time was 25.5 months (from 12 to 48 months). Results: Complete closure with complete resolution of the exudates and flattening of the detachment was observed in five eyes (45%). Visual acuity in the final examination improved or remained stable in 6 cases (55%). Conclusion: These results indicate that diode laser photocoagulation guided by indocyanine green angiography is at least as effective as conventional lasers with shorter wavelengths for treatment of vascularized pigment epithelial detachments in Age Related Macular Degeneration. [source]

    Albumin enhanced morphometric image analysis in CLL,

    CYTOMETRY, Issue 1 2004
    Matthew A. Lunning
    Abstract BACKGROUND The heterogeneity of lymphocytes from patients with chronic lymphocytic leukemia (CLL) and blood film artifacts make morphologic subclassification of this disease difficult. METHODS We reviewed paired blood films prepared from ethylene-diamine-tetraacetic acid (ETDA) samples with and without bovine serum albumin (BSA) from 82 CLL patients. Group 1 adhered to NCCLS specifications for the preparations of EDTA blood films. Group 2 consisted of blood films containing EDTA and a 1:12 dilution of 22% BSA. Eight patients were selected for digital photomicroscopy and statistical analysis. Approximately 100 lymphocytes from each slide were digitally captured. RESULTS The mean cell area ± standard error was 127.8 ,m2 ± 1.42 for (n = 793) for group 1 versus 100.7 ,m2 ± 1.39 (n = 831) for group 2. The nuclear area was 88.9 ,m2 ± 0.85 for group 1 versus 76.4 ,m2 ± 0.83 for group 2. For the nuclear transmittance, the values were 97.6 ± 0.85 for group 1 and 104.1 ± 0.83 for group 2. The nuclear:cytoplasmic ratios were 0.71 ± 0.003 for group 1 and 0.78 ± 0.003 for group 2. All differences were statistically significant (P < 0.001). CONCLUSIONS BSA addition results in the reduction of atypical lymphocytes and a decrease in smudge cells. BSA also decreases the lymphocyte area and nuclear area, whereas nuclear transmittance and nuclear:cytoplasmic ratio are increased. A standardized method of slide preparation would allow accurate interlaboratory comparison. The use of BSA may permit better implementation of the blood film-based subclassification of CLL and lead to a better correlation of morphology with cytogenetics and immunophenotyping. Published 2003 Wiley-Liss, Inc. [source]

    Multicenter clinical experience with flow cytometric method for fetomaternal hemorrhage detection

    CYTOMETRY, Issue 6 2002
    Jenn C. Chen
    Abstract BACKGROUND Enumeration of fetal red blood cells (RBCs) is important in the management of fetomaternal hemorrhage (FMH), particularly in situations of Rh incompatibility. METHODS We evaluated results from three institutions using the flow cytometric method (FCM) to detect fetal RBCs based on the anti-hemoglobin F (HbF) monoclonal antibody method. RESULTS During 1997,2001, 69 of 1,248 patients (5.5%) had measurable fetal erythrocytes (RBCs) in maternal blood. Only 21 patients (1.7%) had more than 30 mL of fetal blood detected in maternal blood. Of the 11 patients with large FMH and clinical follow-up, 7 had fetal demise (64%). In positive samples, significant differences were found in the fluorescence intensity (FI) of anti-HbF antibody staining between HbF-negative erythrocytes (HbF-) and adult HbF containing erythrocytes (F cells; 4 ± 0 versus 57 ± 9 linear mean channels [LMC]; P < 0.001) and between HbF-cells and fetal RBCs (4 ± 0 versus 433 ± 136 LMC; P < 0.001). In addition, significant differences were observed in forward light scatter intensity between HbF-cells and fetal RBCs (298 ± 15 versus 355 ± 68 LMC, P = 0.03). The transportability of the test is also addressed by comparing results from two other laboratories. The experience of our three laboratories, as well as the results from the recently reinitiated College of American Pathologists survey, which compares FCM and manual methods, clearly documents the superiority of the FCM test over the manual Kleihauer-Betke (KB) test. CONCLUSIONS The FCM is a simpler, more objective, and more precise alternative to the KB method in clinical testing. The high mortality rate associated with large FMH and therapeutic implications of these results should give laboratories motivation to abandon the KB method with more robust FCM to detect FMH. Cytometry (Clin. Cytometry) 50:285,290, 2002. © 2002 Wiley-Liss, Inc. [source]

    Visualized Sclerotherapy of Varicose Veins

    BACKGROUND The spread and movement of sclerosant after injection during sclerotherapy is difficult to monitor. OBJECTIVE To develop a new visualization method that allows monitoring of sclerosant dosage and flow during sclerotherapy. METHODS We used a photodynamic eye (PDE) to perform indocyanine green (ICG) imaging. ICG produces strong fluorescence detectable using PDE and allows monitoring of sclerosant spread through blood vessels in real time. We performed visualized sclerotherapy on 50 limbs, comprising high ligation and sclerotherapy (35 limbs), stripping and sclerotherapy (10 limbs), and sclerotherapy alone (5 limbs). RESULTS In all cases, fluorescence imaging of the injected sclerosant was possible. No complications resulted from combining ICG and polidocanol in any of the patients, all of whom received follow-up evaluations at 1 week, 1 month, and 3 months after treatment. CONCLUSIONS Our new method not only avoids the risk of radiation exposure, but also allows for simple observation of sclerosant range of access, determination of the dosage for each lesion, and accurate administration of therapy to target lesions. This method will contribute to further advances in sclerotherapy, given that it allows administration of sclerosant and visual confirmation of optimal injection dosage, speed, and movement of sclerosant after injection. The authors have indicated no significant interest with commercial supporters. [source]

    Crescent Versus Rectangle: Is It a True Negative Margin in Second and Subsequent Stages of Mohs Surgery?

    BACKGROUND The hallmark of Mohs micrographic surgery is using tangential tissue sections that theoretically allow 100% of the tissue margin to be examined, but when taking additional layers for second and subsequent Mohs stages, no detailed methods have been described to ensure that 100% of the tissue margins are analyzed. METHOD A rectangular or a crescent-shaped layer is often used to take second and subsequent stages. Here we compare the two techniques for their theoretic advantages and disadvantages. SUMMARY The advantage of the rectangular shape has been ease of processing, as well as built in vertical "nicks" that automatically mark the border of the tissue removed, but the rectangular layer may not provide 100% evaluation of the tumor margin because the vertical edges of the rectangular layer are not always completely analyzed, and thus tumor cells cannot be visualized in the vertical margins of these layers. This might result in a false-negative margin reading, which can be avoided by using the crescent layer. CONCLUSION We propose taking second and subsequent Mohs layers with only a crescent shape, which allows true 100% tissue margin assessment. The authors have indicated no significant interest with commercial supporters. [source]

    Recent Trends in Cosmetic and Surgical Procedure Volumes in Dermatologic Surgery

    BACKGROUND The number of cosmetic and noncosmetic surgical procedures performed by dermatologic surgeons has been rising rapidly, but there are few consistent data sources allowing procedure volumes to be tracked over time. METHODS American Society for Dermatologic Surgery member survey in 2001 to 2007 reporting cosmetic and noncosmetic procedural volumes (300,500 surgeons surveyed, response rate of 31,44%). RESULTS In 2001, dermatologic surgeons performed an estimated 3.4 million cosmetic and noncosmetic surgical procedures; in 2007, it was estimated that a total of 7.6 million procedures were performed (120.2% rate of growth between 2001 and 2007). The procedures with the greatest increase during this time period were soft tissue augmentation (405.0% increase), botulinum toxin injections (324.4% increase), and nonablative skin rejuvenation (laser, light, and radiofrequency sources) (330.7% increase). More modest increases were noted in skin cancer procedures (85.8% increase) and ablative resurfacing procedures (66.8% increase). CONCLUSION The magnitude of growth in procedural volumes over the last 8 years reflects the advancements in dermatologic surgery in treatments for skin cancer and in treatment of photoaging and cosmetic enhancement of the skin. [source]

    Novel Pretrichial Browlift Technique and Review of Methods and Complications

    BACKGROUND The upper third of the face is integral to our perception of youth and beauty. While the eyelids anchor this facial cosmetic unit, the eyebrows and forehead are intrinsically linked to the upper eyelids, and their position and texture play an important role in creating pleasing eyes as well as conveying mood and youth. The most common browlifts are performed with endoscopic visualization. Yet, this technique requires special equipment and a prolonged learning curve. OBJECTIVE To demonstrate a novel pretrichial technique and to review different browlift methods and their potential adverse effects. METHODS Case series and review of the literature. RESULTS The pretrichial browlift results in a mild to moderate browlift with secondary smoothing of the forehead topography. Aside from bruising and swelling, it results in minimal adverse effects. Other techniques are also effective but may create a larger scar such as a direct browlift, may be more difficult in terms of approach such as the browpexy, or require endoscopes. CONCLUSION Browlifts are an important procedure in rejuvenating the upper third of the face and improving the overall facial aesthetic appearance. The pretrichial browlift is a less invasive open technique that is safe and effective for the appropriate patient. [source]

    Differential Long-Term Stimulation of Type I versus Type III Collagen After Infrared Irradiation

    BACKGROUND The dermis is composed primarily of type I (soft) and type III (rigid scar-like) collagen. Collagen degradation is considered the primary cause of skin aging. Studies have proved the efficacy of infrared irradiation on collagen stimulation but have not investigated the differential long-term effects of infrared irradiation on type I and type III collagen. OBJECTIVE To determine differential long-term stimulation of type I and type III collagen after infrared (1,100,1,800 nm) irradiation. METHODS AND MATERIALS In vivo rat tissue was irradiated using the infrared device. Histology samples were analyzed for type I and III collagen stimulation, visual changes from baseline, and treatment safety up to 90 days post-treatment. RESULTS Infrared irradiation provided long-term stimulation of type I collagen and temporary stimulation of type III collagen. Treatment also created long-term smoothing of the epidermis, with no observed complications. CONCLUSIONS Infrared irradiation provides safe, consistent, long-term stimulation of type I collagen but only short-term stimulation in the more rigid type III collagen. This is preferential for cosmetic patients looking for improvement in laxity and wrinkles while seeking smoother, more youthful skin. [source]

    Improvement of Postfractional Laser Erythema with Light-Emitting Diode Photomodulation

    BACKGROUND The most common side effects of fractional laser skin treatment are erythema and edema. Low-level light therapy and light-emitting diode (LED) devices have been used to stimulate fibroblast activity and hasten wound healing. OBJECTIVE To determine whether LED treatment immediately after fractional laser skin resurfacing affects the severity and duration of postoperative eythema. MATERIALS AND METHODS Twenty patients received treatment with a 590-nm wavelength LED array to randomly selected facial halves immediately after undergoing full-face fractional laser skin resurfacing with a 1,550-nm erbium-doped fiber laser. Differences in erythema between LED-treated and untreated facial halves were recorded at 24, 48, and 96 hours post-treatment. RESULTS The LED-treated facial halves were less erythematous in all 20 patients 24 hours postoperatively. The six patients who received the highest mean energy densities during fractional laser treatment continued to exhibit decreased erythema in the LED-treated areas at 48 hours. At 96 hours post-treatment, no discernible differences between facial halves were observed in any patient. CONCLUSIONS Photomodulation with a 590-nm-wavelength LED array can decrease the intensity and duration of postfractional laser treatment erythema. [source]

    Recent Changes in the Workforce and Practice of Dermatologic Surgery

    BACKGROUND The increasing number of American College of Mohs Surgery (ACMS) fellowship positions over the last decade has resulted in a greater number of fellowship-trained surgeons in dermatologic surgery. METHODS Mohs micrographic fellowship-trained surgeons (MMFTSs) and non-Mohs fellowship-trained surgeons performing Mohs micrographic surgery (NMMFTSs) were compared using the American Academy of Dermatology Practice Profile Survey (2002/05). An analysis of recent Mohs fellowship classes was also performed. RESULTS In 2005, there was an equivalent proportion of MMFTSs and NMMFTSs in the workforce (ratio MMFTS:NMMFTS=0.9) but, in 2005, there was a shift in the youngest age cohort (29,39) to a greater proportion of MMFTSs (MMFTS:NMMFTS=1.55). In 2005, the youngest MMFTSs (29,39) were more likely to be female (47.1%) than of MMFTSs overall (24%). MMFTSs were 5 times as likely to be in full-time academic positions and performed 2 to 3 times as many Mohs cases per week as NMMFTSs. CONCLUSIONS Consistent with demographic shifts in dermatology, differences have emerged in the demographics, surgical volumes, and settings of MMFTSs and NMMFTSs. Recent increases in the ACMS fellowship positions have resulted in a greater proportion of MMFTSs among younger dermatologic surgeons. It will be important to follow how this increase in fellowship trainees affects the dermatologic surgery workforce. [source]

    Prevalence of Methicillin-Resistant Staphylococcus aureus in the Setting of Dermatologic Surgery

    BACKGROUND The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in the postoperative setting of dermatologic surgery is unknown. Such data could influence the empirical treatment of suspected infections. OBJECTIVE To examine the period prevalence of MRSA infections in the postoperative setting of dermatologic surgery. METHODS We performed chart reviews of 70 patients who had bacterial cultures taken from January 2007 to December 2007. In the 21 postsurgical cases, we analyzed age, risk factors, sites of predilection, method of repair, and pathogen of growth. RESULTS The mean age of the overall study population was 57, with the mean age of postsurgical MRSA-positive cases being 75.5. Of the 21 postsurgical cultures taken, 16 cultures grew pathogen, and two of the 16 (13%) pathogen-positive cultures grew MRSA. LIMITATIONS This is a retrospective chart review of a relatively small sample size in one geographic location. Our patient population is known to contain a large number of retirees. CONCLUSION The increasing prevalence of MRSA skin and soft tissue infections and recommendation to modify empirical antibiotic therapy have been well documented in particular patient populations, but we caution against the empirical use of MRSA-sensitive antibiotics in the postoperative setting of dermatologic surgery. We advocate culturing all infectious lesions upon presentation and reserve empirical use of MRSA-sensitive antibiotics for high-risk patients or locations. [source]

    Current Evidence on the Unit Equivalence of Different Botulinum Neurotoxin A Formulations and Recommendations for Clinical Practice in Dermatology

    BACKGROUND The unit equivalence between the two main Botulinum neurotoxin A (BoNTA) preparations, Dysport (Ipsen Ltd., Slough, Berkshire, UK) and BOTOX (Allergan Inc., Irvine, CA), is a matter of discussion. The UK assay used to test Dysport is more sensitive than the U.S. assay used for BOTOX, resulting in a different efficacy per unit in both formulations. Ratios ranging from 6:1 to 1:1 can be found in the literature, but the more recently published literature suggests that 1 unit of BOTOX is equivalent to approximately 2 to 4 units of Dysport (ratio 2:1,4:1). OBJECTIVE Because the number of BoNTA treatments is constantly increasing, these differences warrant a systematic review of published evidence about the unit equivalence of UK and U.S. formulations. METHODS The review is based on a detailed literature research in all relevant databases (MEDLINE, PubMed, Cochrane Library, specialist textbooks). RESULTS The present review supports the recent assumption that dose ratios of less than 3:1 (e.g., 2.5:1 or even 2:1) between Dysport and BOTOX are probably more suitable. CONCLUSIONS The current evidence is still insufficient, and further investigation of lower dose ratios is recommended. [source]

    Collagenase-Assisted Fat Dissociation for Autologous Fat Transfer

    BACKGROUND The quality of fat for autologous transfer procedures has been a major focus of research in the past few years. The primary goal of these efforts is to improve the viability and longevity of the graft in human subjects. One possible factor in the permanence of theses transplants is the size of the adipose tissue grafts. OBJECTIVE This study evaluated the effects of collagenase digestion on the viability of human adipose tissue. MATERIALS AND METHODS Samples of fat were obtained from subjects undergoing tumescent liposuction. The tissue was digested in a variety of concentrations of collagenase using optimized methods of processing. The digested fat was also subjected to mock injections through small bore needles. RESULTS Eight subjects completed the study. The viability of the fat using the optimized methods of collagenase digestion was consistently higher than 79%. During the mock injection trials, the viability of fat was improved from approximately 17% to 84% by collagenase digestion. CONCLUSIONS Our results show increased viability of human adipose tissue when digested by collagenase. These techniques can be applied to human autologous lipoaugmentation procedures in an effort to improve longevity of the transplanted tissue. [source]

    Longitudinal Diminution of Tumor Size for Basal Cell Carcinoma Suggests Shifting Referral Patterns for Mohs Surgery

    BACKGROUND The Mohs technique for removal of cutaneous malignancies offers tissue-sparing benefits compared with other treatment methods. With wider acceptance and availability of Mohs surgery, referral patterns may be shifting toward the treatment of smaller, lower-risk tumors. OBJECTIVE The objective was to examine whether referral patterns for basal cell carcinoma (BCC) at an academic Mohs surgery practice have shifted over recent years toward referral for smaller, lower risk tumors. METHODS A retrospective longitudinal comparison of tumor characteristics was performed for BCCs treated at our institution from a recent year (2004) and a past year (1996). Statistical analyses were used to identify differences in tumor size, distribution by anatomic site, and primary versus recurrent status. RESULTS Complete data were available for 603 BCCs treated in 1996 and 1,514 BCCs treated in 2004. A 24% decrease in preoperative tumor surface area was observed from 1996 (1.25 cm2) to 2004 (0.95 cm2). Tumors were twice as likely to be recurrent in 1996 (15.1%) than in 2004 (7.4%). There were no significant differences in the anatomic distribution of lesions in the years compared. CONCLUSIONS Findings at our institution suggest that in recent years, referral patterns have shifted toward a preference for Mohs surgery for the treatment of smaller, primary BCCs. This may be a result of increased awareness by the dermatologic and medical community of the numerous advantages of Mohs surgery and a greater appreciation of its tissue-sparing properties, which may result in less complex and more successful aesthetic reconstructions. [source]

    Ergonomics in Office-Based Surgery: A Survey-Guided Observational Study

    BACKGROUND The practice of office-based surgery is increasing in many specialties. OBJECTIVE Using Mohs surgery as a model, we investigated the role of ergonomics in office-based surgery to limit work-related musculoskeletal disorders. METHODS All Mayo Clinic surgeons currently performing Mohs surgery and Mohs surgeons trained at Mayo Clinic between 1990 and 2004 received a questionnaire survey between May 2003 and September 2004. A sample of respondents were videotaped during surgery. The main outcome measures were survey responses and an ergonomist's identification of potential causes of musculoskeletal disorders. RESULTS All 17 surgeons surveyed responded. Those surveyed spend a mean of 24 hours per week in surgery. Sixteen said they had symptoms caused by or made worse by performing surgery. Symptom onset occurred on average at age 35.4 years. The most common complaints were pain and stiffness in the neck, shoulders, and lower back and headaches. Videotapes of 6 surgeons revealed problems with operating room setup, awkward posture, forceful exertion, poor positioning, lighting, and duration of procedures. CONCLUSION Symptoms of musculoskeletal injuries are common and may begin early in a physician's career. Modifying footwear, flooring, table height, operating position, lighting, and surgical instruments may improve the ergonomics of office-based surgery. [source]

    Effect of Laser Resurfacing on p53 Expression in Photoaged Facial Skin

    BACKGROUND p53 overexpression has been reported in photoaged skin. Meanwhile, p53 gene mutations have been implicated as an important factor in the pathogenesis of ultraviolet (UV) light,induced skin cancer. OBJECTIVE The objective was to evaluate the effect of laser resurfacing on the epidermal thickness and expression of p53 in photoaged skin. METHODS Specimens were obtained from the facial skin of 10 patients before and after 3 months and 1 year of treatment using CO2 (five cases) and erbium (Er):YAG (five cases) lasers. Specimens were also obtained from six age-matched controls. These biopsies were used for routine histopathology, histometry, and p53 immunoperoxidase staining. RESULTS Both CO2 and Er:YAG lasers were found to induce a significant decrease in p53 expression in biopsies obtained after 3 months (p=.0004 and .002, respectively) followed by gradual increase (p=.01 in both groups). A significant increase (p<.01) in epidermal thickness was also observed after 1 year of resurfacing. This increase, however, is inversely correlated with the level of p53 expression in such patients. CONCLUSION The decrease in epidermal p53 expression after CO2 and Er:YAG lasers may account for some of the benefits of resurfacing on the epidermis, as well as prevention of actinic neoplasia by adjusting any disturbance in the proliferation/apoptosis balance observed in photoaged facial skin. [source]

    Making Scents: Improvement of Olfactory Profile after Botulinum Toxin-A Treatment in Healthy Individuals

    BACKGROUND The axilla is particularly associated with body odor and putative pheromone production in humans. Although botulinum toxin type A (BT-A) is injected increasingly into the axillary skin to stop excessive sweating, its potential to control body odor is largely unexplored. OBJECTIVE The objective was to measure the impact of BT-A on human axillary odor in an objective and reproducible fashion. METHODS This study was a randomized, double-blind, placebo-controlled trial with 51 healthy volunteers receiving 50 U of BOTOX (Allergan, Inc.) in one axilla and placebo in the other. Odor quality was assessed by treated subjects (questionnaire) as well as by independent raters who were exposed to blinded T-shirt samples. RESULTS No major side effects occurred, and no subject withdrew from the study for medical reasons. Samples from the BT-A,treated side smelled less intense (p<.001) and better (p<.001) according to self-assessments. Likewise, independent raters found the BT-A,treated samples to smell less intense and better (p<.001). They preferred "to work together with the respective person" and found the odor "more erotic" (p<.001). CONCLUSION Side-by-side comparison of odor samples (T-shirt sniff test) by independent raters showed that axillary odor in healthy individuals is significantly more appealing after BT-A injection. [source]

    Ice Minimizes Discomfort Associated with Injection of Botulinum Toxin Type A for the Treatment of Palmar and Plantar Hyperhidrosis

    BACKGROUND The value of botulinum toxin type A (BTX-A) for treatment of palmar and plantar hyperhidrosis (HH) has been limited by injection pain, which in the past has generally required administration of a nerve block. We describe the successful use of ice applied to the intended injection point followed immediately by application of either ice or vibration to skin adjacent to the injection point to reduce discomfort associated with injection of BTX-A for the treatment of palmar and plantar HH. RESULTS During needle insertion and injection of BTX-A, both the application of ice to the intended injection point followed by application of ice adjacent to the injection point (ice+ice) and the application of ice to the intended injection point followed by application of vibration adjacent to the injection point have been preferred by our patients to nerve block. These two techniques allow efficient treatment of both hands and/or both feet in a single session. CONCLUSION By eliminating the need for nerve blocks, the techniques described here will enlarge the pool of physicians who can administer BTX-A for palmar and plantar HH, and will enlarge the pool of patients who are willing to have this treatment. [source]

    A Simple, Pain-Free Treatment for Ingrown Toenails Complicated with Granulation Tissue

    BACKGROUND The treatment of ingrown toenail complicated with granulation tissue is usually partial or total nail avulsion with or without matricectomy. It costs loss of occupational power, however, because most patients cannot go to work or school for some time after surgery, and it is a costly and uncomfortable procedure for most patients. OBJECTIVE This study aimed to find an easy, painless, and inexpensive alternative. MATERIALS AND METHODS Seven patients with ingrown toenails complicated with granulation tissue are included. A small apparatus was applied on the nails, granulation tissue was chemically cauterized, and a foot bath was recommended twice daily. They were followed on a weekly basis or every other week until recovery. None of the patients received systemic treatment. RESULTS All seven patients were completely cured without requiring surgery and/or systemic treatment. The procedure did not have any effect on their daily life. The follow-up examination of the patients at 6 months revealed that they were totally cured, and there were no recurrences. CONCLUSION Patients with ingrown toenails complicated by granulation tissue might have an inexpensive and pain-free treatment alternative, although new studies with more patients are required. [source]

    Injectable Hyaluronic Acid Implant for Malar and Mental Enhancement

    BACKGROUND The use of a thicker injectable implant version of one of the hyaluronic acid dermal fillers (Restylane SubQ, Q-Med, Uppsala, Sweden) is described. OBJECTIVE A group of treated patients has been studied for more than 1 year. Restylane SubQ was injected to the submuscular plane of the upper cheeks and chin to observe efficacy of augmentation and side effect profile, and further observations were made of the duration of benefit. METHODS Patient details,72 patients were treated, 68 for upper cheek augmentation, 2 for chin augmentation, and 2 for both areas. Four patients received second injections 8 weeks after the first to increase augmentation. RESULTS Patients all showed a persistence of benefit during the posttreatment observation period of up to 64 weeks. Four patients had minor side effects that resolved with local treatment and time. Four patients had second injections to complete augmentation without complications. CONCLUSIONS Restylane SubQ is a useful injectable agent to augment and lift upper cheeks and recontour chins. Further efficacy studies seem justified. [source]

    Melanoacanthoma Simulating Pigmented Spitz Nevus: an Unusual Dermoscopy Pitfall

    BACKGROUND The starburst pattern is the dermoscopic hallmark of pigmented Spitz nevus, although it has been rarely observed in melanoma as well. OBJECTIVE To describe a case of melanoacanthoma simulating pigmented Spitz nevus. MATERIAL AND METHODS Clinical, dermoscopic, and histopathologic examinations were performed for the occurrence of a 4-mm pigmented skin lesion on the hip of a 38-year-old Caucasian woman. RESULTS Dermoscopy examination of the lesion disclosed a stereotypical starburst pattern characterized by pigmented streaks symmetrically distributed at the periphery. A preoperative diagnosis of pigmented Spitz nevus was made, and the lesion was excised. However, subsequent histopathologic examination revealed a melanoacanthoma. CONCLUSION The starburst pattern, although diagnostic for pigmented Spitz nevus, can be rarely observed in other benign or malignant pigmented skin lesions. Accordingly, all lesions in adults exhibiting a starburst pattern or other spitzoid features should be excised for histopathologic evaluation. [source]

    Sterile Versus Nonsterile Gloves During Mohs Micrographic Surgery: Infection Rate is not Affected

    BACKGROUND: Mohs micrographic surgery (MMS) is an outpatient procedure, which has become the treatment of choice for certain cutaneous malignancies. Although the major steps in this procedure are relatively standardized, one difference involves the use of sterile or nonsterile, clean gloves during the tumor removal phase. OBJECTIVE: This retrospective, chart review study was performed to evaluate whether infection rates are affected by the use of sterile versus nonsterile gloves in the tumor extirpation phase of MMS. METHODS: This study evaluated the surgical records of 1,810 consecutive Mohs patients, of which 1,239 Mohs patients (1,400 Mohs procedures) met inclusion criteria. Age, sex, tumor diagnosis, anatomic location, number of Mohs stages, area of defect, closure type, cartilage exposure, and sterile versus nonsterile glove use were recorded and evaluated. RESULTS: Twenty-five infections were identified. Statistically significant infection rates were discovered for patients with cartilage fenestration with secondary healing and malignant melanoma diagnosis only. There was no statistical difference in infection rates with all other measured variables to include the use of sterile or clean, nonsterile gloves. CONCLUSION: Our study lends support that clean, nonsterile gloves are safe and effective for use in the tumor extirpation phase of MMS, at a significant cost savings. [source]

    Hemorrhagic Bullae After Cryosurgery in a Patient With Hemophilia A

    John G. Hancox MD
    BACKGROUND. A case of hemorrhagic bullae and blisters on the hand of a patient with hemophilia A after cryosurgery for verruca vulgaris is reported. OBJECTIVE. To discuss a hemorrhagic complication in a patient with hemophilia A after cutaneous cryosurgery. METHODS. This is an observatory case report. RESULTS. Even minimal cryosurgery can induce hemorrhagic bullae in patients with hemophilia A. CONCLUSION. The risks and benefits of cryosurgery should be weighed carefully in patients with bleeding disorders such as hemophilia. [source]