Melatonin and Sleep in Preventing Hospitalized Delirium: A Randomized Clinical Trial.

PURPOSE: Studies suggest that melatonin may prevent delirium, a condition of acute brain dysfunction occurring in 20%-30% of hospitalized older adults that is associated with increased morbidity and mortality. We examined the effect of melatonin on delirium prevention in hospitalized older adults while measuring sleep parameters as a possible underlying mechanism. METHODS: This was a randomized clinical trial measuring the impact of 3 mg of melatonin nightly on incident delirium and both objective and subjective sleep in inpatients age ≥65 years, admitted to internal medicine wards (non-intensive care units). Delirium incidence was measured by bedside nurses using the confusion assessment method. Objective sleep measurements (nighttime sleep duration, total sleep time per 24 hours, and sleep fragmentation as determined by average sleep bout length) were obtained via actigraphy. Subjective sleep quality was measured using the Richards Campbell Sleep Questionnaire. RESULTS: Delirium occurred in 22.2% (8/36) of subjects who received melatonin vs in 9.1% (3/33) who received placebo (P = .19). Melatonin did not significantly change objective or subjective sleep measurements. Nighttime sleep duration and total sleep time did not differ between subjects who became delirious vs those who did not, but delirious subjects had more sleep fragmentation (sleep bout length 7.0 ± 3.0 vs 9.5 ± 5.3 min; P = .03). CONCLUSIONS: Melatonin given as a nightly dose of 3 mg did not prevent delirium in non-intensive care unit hospitalized patients or improve subjective or objective sleep.

Sound and Light Levels Are Similarly Disruptive in ICU and non-ICU Wards.

OBJECTIVE: To compare ambient sound and light levels, including SLCs, in ICU and non-ICU environments. DESIGN: Observational study. SETTING: Tertiary-care hospital. MEASUREMENTS: Sound measurements of 0.5 Hz were analyzed to provide average hourly sound levels, sound peaks, and SLCs =17.5 decibels (dB). For light data, measurements taken at 2-minute intervals provided average and maximum light levels. RESULTS: The ICU rooms were louder than non-ICU wards; hourly averages ranged from 56.1 ± 1.3 dB to 60.3 ± 1.7 dB in the ICU, 47.3 ± 3.7 dB to 55.1 ± 3.7 dB on the telemetry floor, and 44.6 ± 2.1 dB to 53.7 ± 3.6 dB on the general ward. However, SLCs = 17.5 dB were not statistically different (ICU, 203.9 ± 28.8 times; non-ICU, 270.9 ± 39.5; P = 0.11). In both ICU and non-ICU wards, average daytime light levels were <250 lux, and peak light levels occurred in the afternoon and early evening. CONCLUSIONS: Quieter, non-ICU wards have as many SLCs as ICUs do, which has implications for quality improvement measurements. Efforts to further reduce average noise levels might be counterproductive. Light levels in the hospital (ICU and non-ICU) may not be optimal for maintenance of a normal circadian rhythm for most people.

Clinical and histologic effects of facial skin rejuvenation with pulsed- and continuous-wave flash-scanned CO(2) lasers.

LEARNING OBJECTIVES: The reader is presumed to have some understanding of the use of lasers in skin resurfacing. After studying the article, the participant should be able to: Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 409. BACKGROUND: The selection of the ideal laser for facial resurfacing is debatable. OBJECTIVE: The purpose of the study was to determine whether any clinical and histologic differences existed in short- and long-term results after treatment with the Coherent UltraPulse 5000G laser (a pulsed laser; PL) and the Sharplan Silk Touch laser (a continuous-wave laser [CWL] with a flash scanner). METHODS: Eight patients underwent facial resurfacing treatment on different areas. In each case, one side was treated with the PL and the other with the CWL. The condition of the patients and the treated tissue were monitored periodically after treatment. Histologic assessment of punch biopsies was performed 3 months and 1 year after treatment with hematoxylin-eosin, Masson trichromic, and Verhoeff's stains. RESULTS: The areas treated with the PL achieved earlier epithelialization with a good appearance. Longer-lasting erythema was observed on the side treated with the CWL. On a histologic level, although the PL-treated tissue epithelialized more quickly, at 3 months and 1 year the collagen was better compacted and better aligned in the CWL-treated tissue, and the macroscopic appearance of the CWL-treated areas was more enhanced. CONCLUSIONS: The more active vascularization seen in the CWL-treated tissue, associated with the longer-lasting erythema and possibly greater collateral thermal injury, is possibly the reason for the better collagenization and remodeling of collagen and elastin fibers as compared with the results with the PL-treated tissue. This may explain the longer effect associated with CWL treatment. The clinician would do well to bear in mind the histologic findings as well as the macroscopic clinical results when assessing the long-term effects of laser skin resurfacing. (Aesthetic Surg J 2001;21:399-411.).

Estudio de cohorte prospectiva de un programa de seguimiento farmacoterapéutico a pacientes anticoagulados ingresados en residencias geriátricas / Prospective cohort study of a pharmacological follow-up program of anticoagulated patients admitted to nursing homes

Introducción: El tratamiento anticoagulante, pese a conseguir un claro beneficio para prevenir y tratar la patología tromboembólica, presenta dificultades para su manejo en la práctica habitual. Ello debido a la variabilidad individual de dosificación, estrecho margen terapéutico, interacciones farmacológicas y efectos secundarios graves. Los pacientes ingresados en residencias geriátricas presentan cada vez más indicaciones para seguir un tratamiento anticoagulante oral, producto de trombosis venosa profunda y, muy especialmente, fibrilación auricular. Se trata de pacientes con un perfil que dificulta la prescripción del tratamiento anticoagulante: edad avanzada, polimedicación y pluripatologías. Objetivos: nos planteamos la hipótesis de que la implantación desde atención primaria de un programa de seguimiento farmacoterapéutico del tratamiento anticoagulante oral en pacientes ingresados en residencias geriátricas, que coordine a distintos profesionales de diferentes estamentos y niveles asistenciales, ha de mejorar su beneficio y disminuir los efectos secundarios. Métodos: se realiza un estudio descriptivo tipo cohorte prospectiva, de un año de evolución, de 27 pacientes ingresados en residencia geriátrica que realizan tratamiento anticoagulante controlado por el equipo de atención primaria. Se analizan distintas variables obtenidas a partir de la historia clínica informatizada, a partir de las cuales se establecen indicadores sobre el procedimiento del programa (indicadores de cobertura y registro) y otros sobre el resultado (indicadores definidos por el Comité Británico de Estándares en Hematología). Resultados: los resultados muestran que el perfil del paciente ingresado en una residencia geriátrica tratado con anticoagulantes es de edad avanzada (84 años), con predominio de mujeres (70 por ciento), con fibrilación auricular como indicación más frecuente (70,4 por ciento)...

Introduction. Anticoagulant treatment, despite providing a clear benefit to prevent and treat thrombo-embolic disease, is difficult to manage in routine practice. This is due to individual variability of dosing, narrow therapeutic margin, drug interactions, and side effects. An increasing number of patients admitted to nursing homes are under oral anticoagulant therapy because of deep venous thrombosis and, especially, atrial fibrillation. These are patients with a profile that makes prescription of anticoagulant treatment more difficult - elderly, taking multiple concomitant medications and with multiple ailments. Objetive. We hypothesized that the implementation of a primary care pharmacological follow-up program of oral anticoagulant therapy in patients admitted to nursing homes, with the purpose of coordinating the different professionals and care levels, would lead to greater benefit and reduction of side effects. Methods. A one-year descriptive prospective cohort study was conducted of 27 patients admitted to nursing homes who are under anticoagulation therapy followed by the primary care team. We analyzed different variables obtained from computerized medical records, from which indicators on the program were established (coverage and registration) as well as outcome indicators (as defined by the British Committee for Standards in Haematology). Results. The profile of patients under anticoagulation and admitted to nursing homes is elderly (84 years), with a predominance of women (70 percent), atrial fibrillation as most frequent indication (70.4 percent), hypertension as major cardiovascular risk factor (92 percent) and most of them on multiple drugs (92 percent). The analysis of the program results showed excellent coverage and registration indicators (100 percent)...

Skin resurfacing improved with a new dual wavelength Er:YAG/CO2 laser system: a comparative study.

OBJECTIVE: The efficacy of a new dual wavelength Er:YAG and CO2 laser system was tested for skin resurfacing results on rabbits' ears and human facial skin. The dual wavelength laser delivers simultaneous pulses of low-energy CO2 and high-energy Er:YAG energies. Theoretically, combining the strengths of both laser types in one console should lead to improved clinical outcome. SUMMARY BACKGROUND DATA: The use of the laser for skin resurfacing and remodeling has dramatically increased over the past few years. The CO2 laser was the first laser to be used in this field, followed more recently by the E:YAG laser. Both lasers offer unique advantages and disadvantages. METHODS: The present study consists of an ear chamber experiment, conducted on eight rabbits, to examine vascular network formation, after laser resurfacing with a standard CO2 laser and the Er:YAG/CO2 laser. Resurfacing was also performed on human patients with the Er:YAG/CO2 laser and the results were compared with previously published results of CO2 laser resurfacing. RESULTS: Significant advantages, including an attenuation in the degree of edema and erythema and a shorter reepithelialization time compared to results with conventional CO2 systems, were observed with the Er:YAG/CO2 system. Improved tissue reorganization and good clinical results in nine of the ten patients (six ratings of "very good" and three "good") were observed. The clinical outcome of the remaining patient was rated as "fair." Minimal side effects were reported and observed in only three patients. The learning curve required to maximize the efficiency of the system is steep, however, requiring a thorough understanding of the different laser/tissue interactions associated with the two wavelengths. CONCLUSION: It is the authors' opinion that the dual wavelength Er:YAG/CO2 laser system offers a particularly efficient and flexible system to perform standard CO2 procedures for skin resurfacing with an improved clinical outcome, as well as other applications with the CO2 or Er:YAG energy delivered separately.

The filtrum remodelling with combined Er:YAG CO2 laser resurfacing.

BACKGROUND: Upper lip wrinkles develop with aging and they can be successfully treated with laser resurfacing. The treatment eliminates the wrinkles and, ideally, should also recover the aesthetic configuration. METHODS: This report includes 32 patients treated for wrinkles of the upper lip with the Derma K. The first pass was done using 29 J/cm2, 5 Hz, 3 mm collimated spot size, plus the CO2 laser 5 W, 50% duty cycle, 50% overlapping. Following this pass, Derma K was reprogrammed to emit only with the Er:YAG at 1.4 J/cm2, 10 Hz, approximately 50% overlapping and with a beam diameter of 3 mm. Then, several passes were done where wrinkles could still be seen, focusing on the area corresponding to the filtrum. Biopsies were taken to examine possible particular implications of underlying muscle and its role in the recovery of anatomic aesthetics of young lip characteristics when using the proposed technique. RESULTS: Using Derma K resurfacing with extra passes of the Er:YAG at relatively low density, at the aforementioned area, it was possible to achieve the recovery of the aesthetic youthful appearance of the upper lip. Also, the shape of the filtrum recovered its youthful appearance together with the cupid's bow shape. Histology samples collected at the end of resurfacing showed that the laser thermal effect was also related to muscle fibres due to the proximity of this layer to the dermis because of the narrow subcutaneous fat layer. CONCLUSION: The combination of Er:YAG and CO2 laser of Derma K has potential to enhance the results of resurfacing for elimination of wrinkles of the upper lip. Moreover, the fact that only one laser pass of high energy density is used permits clear and secure control of treatment, preventing complications and obtaining good results.

Controlled vaporization of the skin for the treatment of wrinkles.

Resurfacing with CO(2) or Er:YAG lasers is a frequent technique used to achieve skin rejuvenation. The Er:YAG has gained wide acceptance since it can reduce the morbidity associated with CO(2) resurfacing. Laser resurfacing with the CO(2) produces areas of fibroplasia with intense cellular and vascular activity. Thermal conduction towards neighbouring tissue is the cause of collagen production which acts in stretching the skin. Despite the scarce thermal conduction of the Er:YAG laser, areas of fibroplasia are also found after resurfacing. But, this may be associated with the relatively low energy density used, which provokes an increase in the thermal gradient deposited causing stimulation in the dermis. One advantage of a CO(2) and Er:YAG combined system is that it produces limited tissue aggression. High energy density Er:YAG in combination with subablative CO(2) can obtain effective epidermis elimination by the former and heat conduction for the dermis contraction by the latter. Laser is a safe, valid alternative treatment for cutaneous aging but prudence, together with observation should continuously guide skin resurfacing.

The significance of orbital anatomy and periocular wrinkling when performing laser skin resurfacing.

Knowledge of orbital anatomy and the interaction of muscle contractions, gravitational forces and photoagingis fundamental in understanding the limitations of carbon dioxide (CO2) laser skin resurfacing when rejuvenating the skin of the periocular area. Laser resurfacing does not change the mimetic behavior of the facial muscles nor does it influence gravitational forces. When resurfacing periocular tissue, the creation of scleral show and ectropion are a potential consequence when there is an over zealous attempt at improving the sagging malar fat pad and eyelid laxity by performing an excess amount of laser passes at the lateral portion of the lower eyelid. This results in an inadvertent widening of the palpebral fissure due to the lateral pull of the Orbicularis oculi. Retrospectively, 85 patients were studied, who had undergone periorbital resurfacing with a CO2 laser using anew treatment approach. The Sharplan 40C CO2 Feather Touchlaser was programmed with a circular scanning pattern and used just for the shoulders of the wrinkles. A final laser pass was performed with the same program over the entire lower eyelid skin surface, excluding the outer lateral portion (e.g. a truncated triangle-like area),corresponding to the lateral canthus. Only a single laser pass was delivered to the lateral canthal triangle to avoid widening the lateral opening of the eyelid, which might lead to the potential complications of scleral show and ectropion. When the area of the crows' feet is to be treated, three passes on the skin of this entire lateral orbital surface are completed by moving laterally and upward toward the hairline. Patients examined on days 1, 7, 15, 30, 60, and one year after laser resurfacing showed good results. At two months after treatment, the clinical improvement was rated by the patient and physician as being "very good" in 81 of the 85 patients reviewed. These patients underwent laser resurfacing without complications. The proposed technique of periocular resurfacing prevents complications of scleral show and laxity in the lateral eyelid opening and even ectropion, because treatment conforms to the osseo-muscular anatomical relationship of eyelid structures.

Electron microscopy comparison of CO2 laser flash scanning and pulse technology one year after skin resurfacing.

BACKGROUND: The recent adaptation of laser technology in plastic and dermatologic surgery has provided a means to reduce efficiently the irregularities of the surface of the skin. Previous studies have analyzed the short- and medium-term clinical and histologic results of two laser systems: the Sharplan 40C SilkTouch and the 5000C Coherent Ultrapulse with Computer Pattern Generator (CPG). This paper contains the long-term ultrastructural findings observed with the aid of transmission electron microscopy (TEM). MATERIALS AND METHODS: Twenty skin biopsy specimens were taken from ten Caucasion patients, between 54 and 72 years of age, who had undergone facial skin resurfacing with a CO2 laser 1 year previously. The treated areas of the face were divided into two equal parts. One half of the face was treated with the Sharplan SilkTouch laser and the other half with the Coherent Ultrapulse laser. Using TEM, the cell composition of the epidermis was studied ultrastructurally, as were the dermal-epidermal junction (DEJ) and the different fibers and cells in the superficial and middle dermis. RESULTS: On the side treated by the Sharplan laser, little melanin was observed, the DEJ was thicker, and there were abundant collagen fibers well compacted in the dermis. Also present was abundant elastin fiber with scarce interstitial spaces. On the side treated by the Coherent, the melanin was abundant and the DEJ was well structured. There were fibroblasts with lax chromatin in the dermis and collagen fibers in the papillary dermis oriented in a vertical and horizontal manner in relation to the epidermis. There was little elastin. The interstitial spaces were abundant. CONCLUSIONS: The Sharplan laser system seems to provoke a significantly more intense tissue response, with abundant dermal collagen and elastic fibers. This indicates that the Sharplan 40C SilkTouch might produce longer lasting clinical effects.

Patients' answers to a postoperative questionnaire related to laser resurfacing.

To date there is no information that evaluates, from the patient's point of view, the experience of undergoing CO(2) laser skin resurfacing. This article investigates the outcome of laser resurfacing for various cutaneous problems with respect to the patient's expectations and experiences and the surgeon's opinions. Patients were entered into the study prospectively and presented with a questionnaire, at 12 months after treatment, to evaluate the patient's skin resurfacing experience. All patients received standardized preoperative counseling and underwent a standardized surgical protocol, conducted by the same surgeon. Eighty-eight percent of patients considered the result of the laser resurfacing to be very good, and 97% indicated that they had experienced little pain or discomfort. Nevertheless, 77% of patients stated that they would be unwilling to undergo another resurfacing procedure. This discrepancy is most likely the result of the patients' experiences in relation to the degree of erythema afterward. Most patients stated a desire to have more information regarding the procedure, particularly with respect to their experiences concerning postoperative erythema and exudates in the treated area. From the study it can be concluded that patients require extensive preoperative counseling, including a full explanation of all possible sequelae of these procedures to improve the patient's experience.

Chloracne in the 1990s.

BACKGROUND: Chloracne is a disease associated with toxicity of halogenated compounds used in some industrial processes. A patient affected by chloracne led us to study a total of nine cases from a single factory. METHODS: We studied the clinical features of nine patients exposed chronically to chlorobenzenes. On all of them blood samples were drawn and biopsies of affected skin and liver were taken. Their work environment was visited and studied. RESULTS: All nine patients were men and had polymorphic skin lesions, characterized mainly by comedones and cysts. They had chronic conjunctivitis and seven had cysts in the Meibomian glands. All of them had polyneuropathy and liver damage and seven had hypertriglyceridemia. Compounds known to cause chloracne were found in exceedingly high concentrations in the water used in the workplace. CONCLUSIONS: Every patient exposed to halogenated compounds with the cutaneous manifestations of chloracne should be carefully investigated for systemic complications (such as ophthalmic, neuropathic, hepatic, and lipoprotein abnormalities).