Global health diplomacy-reconstructing power and governance.

Over the past two decades, global health diplomacy, foreign policy for health, and global health policy have changed substantially. Diplomacy is a constitutive part of the system of global health governance. COVID-19 hit the world when multilateral cooperation was subject to major challenges, and global health has since become integral to geopolitics. The importance of global health diplomacy, especially at WHO, in keeping countries jointly committed to improving health for everyone, has once again been shown. Through a systematic review, this Series paper explores how international relations concepts and theories have been applied to better understand the role of power in shaping positions, negotiations, and outcomes in global health diplomacy. We apply an international relations perspective to reflect on the effect that those concepts and theories have had on global health diplomacy over the past two decades. This Series paper argues that a more central role of international relations concepts and theories in analysing global health diplomacy would help develop a more nuanced understanding of global health policy making. However, the world has changed to an extent that was not envisioned in academic discourse. This shift calls for new international relations concepts and theories to inform global health diplomacy.

Versatility of the O-Z Flap in the Reconstruction of Facial Defects.

BACKGROUND: The O-Z flap has traditionally been used for surgical defects adjacent to critical anatomic structures requiring a repair option that minimizes distortion and functional impairment. However, another advantage of the O-Z flap is that it is tissue conservative, particularly in comparison to primary closure. In fact, the design simply takes the Burow's triangles that would be discarded and rotates them inward. OBJECTIVE: The purpose of this work is to detail the type of post-Mohs defects, which might benefit from consideration of the O-Z flap with emphasis on tissue conservation and restoration of contour to the surgical site. Furthermore, the authors wish to describe unique considerations in each location and methods to appropriately plan the O-Z flap in each circumstance. METHODS AND MATERIALS: The authors reviewed all flaps classified as O-Z in their tumor registry. The approximate size of the defect reconstructed, complications, and long-term outcomes were recorded. RESULTS: O-Z flap implementation is described in detail for repair of defects located at the lateral nasal tip, nose-cheek junction, medial canthus, and mid-cheek. CONCLUSION: The O-Z flap can be effectively used to repair defects located at the lateral nasal tip, nose-cheek junction, medial canthus, and mid-cheek. It is a mechanically simple flap with predictable tension vectors, which can be specifically oriented to protect the free margin.

Incidence of infection after Mohs micrographic and dermatologic surgery before and after implementation of new sterilization guidelines.

BACKGROUND: Clinical guidelines regarding surgical instrument sterilization established by accrediting organizations should be based on peer-reviewed scientific literature. Few data exist in the scientific literature to support the changes in sterilization protocols imposed by accrediting organizations. OBJECTIVE: We sought to determine whether recently established guidelines for the sterilization of surgical instruments have had any clinical impact on postsurgical infection rates. METHODS: Infections rates after excisional and Mohs micrographic surgery before and after implementation of new Joint Commission on the Accreditation of Healthcare Organizations sterilization guidelines were examined retrospectively. All surgeries were performed at an academic outpatient office. RESULTS: In all, 1415 patients underwent a total of 1688 surgeries. No significant differences were observed in mean patient age (P = .113), mean number of Mohs micrographic surgical levels (P = .067), final defect size (P = .305), patient gender (P = .072), repair type (P = .691), or infection rate (P = .453). No major differences in predisposing factors were identified in patients who developed postsurgical infections. LIMITATIONS: This was a retrospective study conducted at a single academic institution. CONCLUSIONS: In our practice, recent changes in surgical instrument sterilization protocols have had no impact on postsurgical infection rates. The implementation of such guidelines places an additional burden on the health care system without providing any improvement in patient outcomes.

Evaluation of orbicularis oculi muscle stripping on the cosmetic outcome of upper lid blepharoplasty: a randomized, controlled study.

BACKGROUND: Many variations in the surgical treatment of upper eyelid blepharoplasty have been described, including orbicularis oculi muscle stripping. There is no evidence in the literature to support the efficacy of this technique in improving the aesthetic results of the procedure. OBJECTIVES: To conduct a single-blind, randomized, controlled, split-face pilot study to evaluate the effects of orbicularis oculi muscle stripping on upper lid blepharoplasty. METHODS: Ten subjects were randomized to receive upper lid blepharoplasty with orbicularis oculi muscle stripping on one side and skin-only blepharoplasty on the other. Patients and two blinded physicians evaluated the aesthetics of the eyelids at 1-, 3-, and 17-month follow-up visits. RESULTS: Blinded physician evaluation failed to show a difference in the overall cosmetic appearance of the eyelids between the control and treatment sides at any time point. Analysis of the composite of all patient scores showed a trend favoring the control side at 3 months (p = .28) and the treatment side at 17 months (p = .50), but neither difference was significant. CONCLUSION: Based on the data from this pilot study, orbicularis oculi muscle stripping appears to have no affect on the aesthetic outcome of upper lid blepharoplasty.

Evaluation of clinical results, histological architecture, and collagen expression following treatment of mature burn scars with a fractional carbon dioxide laser.

OBJECTIVE: To assess mature burn scars treated with a fractional carbon dioxide laser for changes in histological architecture, type I to III collagen ratios, density of elastic tissue, and subjective measures of clinical improvements. DESIGN: Uncontrolled, prospective study of patients with mature burn scars, from a clinical and histological perspective. Biopsy specimens were obtained before and 2 months after 3 treatment sessions. The tissue was prepared with Verhoff von Giesen (VVG) stain to discern elastic tissue and Herovici stain to differentiate types I and III collagen. SETTING: Subjects were recruited from the Grossman Burn Centers. PARTICIPANTS: Of 18 patients with mature burn scars, 10 completed the entire treatment protocol. INTERVENTION: Participants received 3 treatments with a fractional carbon dioxide laser. MAIN OUTCOME MEASURES: Vancouver Scar Scale and Patient and Observer Scar Assessment Scale survey scores. In histological analysis, imaging software was used to measure changes in collagen subtype and elastic tissue. A rating scale was developed to assess normal vs scar architecture. RESULTS: The first hypothesis that significant histological improvement would occur and the second hypothesis of a statistically significant increase in type III collagen expression or a decrease in type I collagen expression were confirmed. There were no significant changes in elastic tissue. Statistically significant improvements were seen in all survey data. CONCLUSIONS: Treatment with a fractional carbon dioxide laser improved the appearance of mature burn scars and resulted in a significant improvement in collagen architecture following treatment. Furthermore, in treated skin specimens, a collagen subtype (types I and III collagen) profile resembling that of nonwounded skin was found.

Clinical and molecular effects on mature burn scars after treatment with a fractional CO(2) laser.

BACKGROUND AND OBJECTIVE: There have been several case reports of improvement in the appearance of mature burn scars following treatment with fractional CO(2) lasers. However, the biochemical mechanisms responsible for these improvements have not been elucidated. MATERIALS AND METHODS: Ten patients with mature, full-thickness, hypertrophic burn scars received initial treatment with a fractional CO(2) laser. Clinical improvement was measured with Vancouver Scar Scale as well as Patient and Observer Scar Assessment Scale. Fresh tissue samples were obtained before the initial treatment and 48 hours after the first treatment for TaqMan Real-time RT-PCR analyses. Expressions of several scar-related biological markers, including types I and III procollagen, matrix metalloproteinase (MMP)-1, -13, transforming growth factor (TGF)-ß1, ß2, ß3, and basic fibroblast growth factor (bFGF), as well as microRNA miR-17-92 cluster, were investigated. RESULTS: There were significant improvements in both observer and subject ratings in all scales. Both types I and III procollagen mRNA levels were dramatically down-regulated after treatment, but the ratio of types I/III procollagen mRNA was not different. The expression of MMP-1 was significantly up-regulated after treatment, while TGF-ß2, -ß3, and bFGF levels were significantly down-regulated. Expression of miR-18a and miR-19a were dramatically up-regulated (P < 0.05) after treatment. CONCLUSIONS: Our study indicated that fractional CO(2) resulted in clinical improvement of mature burn scar. Alteration of types I and III procollagen, MMP-1, TGF-ß2, -ß3, bFGF, as well as miRNAs miR-18a and miR-19a expression may be responsible for the clinical improvement after treatment. Our finding may have implications for novel treatments and further our understanding of fractional CO(2) laser treatment.

Pulsed dye laser and pulsed dye laser-mediated photodynamic therapy in the treatment of dermatologic disorders.

BACKGROUND: The pulsed dye laser (PDL) is used for treating cutaneous vascular disorders. Recent reports have also shown its effectiveness in conditions of other etiologies, although the precise mechanisms of action are unknown. PDL has also been used in photodynamic therapy (PDT) for many dermatologic conditions. We review the broad array of disorders that can be effectively managed using the PDL. OBJECTIVES AND METHODS: A review of the literature on the application of the PDL and PDL-mediated PDT in dermatologic disorders. A literature-based search was performed using PubMed from 1997 to 2010. Search terms included: "pulsed dye laser," "pulsed dye laser photodynamic therapy," and "pulsed dye laser indications." RESULTS: The PDL was initially designed for cutaneous vascular disorders. Recent investigations have demonstrated successful results when treating malignant, inflammatory, viral, and collagenous conditions. Side effects, including pain, purpura, edema, and postinflammatory hyperpigmentation, were mild, well tolerated, and transient. CONCLUSIONS: PDL is accepted as first-line therapy for vascular disorders including port-wine stains, telangiectasias, and hemangiomas. PDL causes selective photothermolysis of dermal vasculature. This mechanism also allows it to be applicable for disorders of other etiologies. Recent studies suggest that the PDL may induce cytokine expression and collagen formation, further increasing its applicability in dermatology.

Recommendations and current practices for the reconstitution and storage of botulinum toxin type A.

BACKGROUND: Current guidelines from the Centers for Disease Control and Prevention (CDC) regarding the reconstitution and storage of botulinum toxin type A (BT-A) differ from those of the Centers for Medicare and Medicaid Services and current clinical practice. CDC guidelines require single-patient use of BT-A vials. Strict adherence to these guidelines creates waste and a significant financial impediment, and does not confer increased protection from infection, assuming standard safe injection practices are followed. OBJECTIVE: This study examines current clinical practices and provides expert consensus recommendations regarding the reconstitution and storage of BT-A. A review of the literature on the sterility and efficacy of BT-A stored beyond the recommended time period of 4 hours is also presented. METHODS: An Internet-based survey was used to analyze the current practices of physician members of the American Society for Dermatologic Surgery who administer botulinum type A toxins. RESULTS: After reconstitution, the majority of physicians (68.6%) routinely store BT-A for a period of greater than 1 week and safely use each toxin vial for more than one patient. Not a single case of infection was observed. LIMITATIONS: This was a single survey with a 32.2% response rate. CONCLUSION: A single vial of BT-A can be safely administered to multiple patients, assuming standard safe injection techniques are followed. After reconstitution, Our data suggest that BT-A can be stored beyond the recommended time period of 4 hours.

Livedo reticularis from amantadine.

A 70-year-old Caucasian man with a medical history of Parkinson's disease presented with a 3-month history of violaceous reticulated patches on his upper and lower extremities. The lesions were asymptomatic. The patient did not have a history of cardioembolic events or autoimmune disorders. No new medications were started before the onset of the lesions. Review of systems was unremarkable. On examination, large erythematous to violaceous patches were present in a reticulated net-like pattern on the patient's upper and lower extremities (Figure 1 and Figure 2). No edema, erosions, or ulcerations were noted. An extensive workup for autoimmune, infectious, and hematologic causes of livedo reticularis was performed. Complete blood cell count, anti-nuclear antibodies (ANAs), anti-Ro and anti-La antibodies, antiphospholipid antibodies, protein C and S levels, cryoglobulin screen, rheumatoid factor, and hepatitis screen were all within normal limits. After these potential other causes were excluded, the patient was diagnosed with amantadine-induced livedo reticularis (LR), a medication he had been taking for 2 years for Parkinson's disease. The patient's dose of amantadine was decreased from 100 mg to 50 mg twice daily and over the next few months, his lesions gradually faded. Because his neurologic condition benefited from amantadine and his lesions were asymptomatic, his neurologist continued the medication.

Current methods employed in the prevention and minimization of surgical scars.

BACKGROUND: Postsurgical scars are of significant concern to patients and surgeons. Many studies have focused on different treatment options for established surgical scars. The prevention and minimization of such aberrant healing responses is more likely to yield better outcomes and require less time and expense. OBJECTIVE AND METHOD: A review of the literature on various forms of prophylactic treatments intended to prevent or minimize the development of prominent postsurgical scars was performed using the Pubmed database over a period from 1987 to 2010. Search terms included "scar prevention," "scar minimization," "post-surgical scar management," and "surgical scars." RESULTS: Various over-the-counter topical products commonly used by patients have failed to demonstrate any significant benefits in improving final scar outcomes. Numerous interventions performed around the time of surgery, including botulinum toxin, lasers, and intradermal injectable products, have shown effectiveness in minimizing eventual scar appearance. CONCLUSIONS: Patient education on proper wound care is a simple method of improving the cosmetic appearance of surgical scars. At the other end of the spectrum, our knowledge of the complex mechanisms of wound healing has allowed for the development of new, effective treatment modalities, including lasers, botulinum toxin, cytokines, and stem cells.

Subcuticular incision versus naturally sourced porcine collagen filler for acne scars: a randomized split-face comparison.

BACKGROUND: Subcuticular incision is performed to release fibrotic bands beneath acne scars and to stimulate neocollagenesis. Naturally sourced porcine collagen has been approved for filling moderate to deep facial wrinkles and nasolabial folds. To our knowledge, naturally sourced porcine collagen filler has not yet been tried as a treatment for correcting atrophic acne scars. OBJECTIVE: To objectively assess and directly compare the efficacy and safety of subcuticular incision versus naturally sourced porcine collagen dermal filler in correcting atrophic and rolling acne scars. MATERIALS AND METHODS: We performed a prospective, randomized, split-face, single-blind study to evaluate intermediate long-term efficacy of subcision and collagen dermal filler on 20 unilateral faces. Patients and blinded physicians evaluated results. RESULTS: Patients rated subcision as superior to collagen dermal filler at 3 months (p=.03). At 6 months, subcision had a slightly higher rating than collagen dermal filler (p=.12). Blinded evaluators leaned toward subcision at 3 months (p=.12) and at 6 months showed no preference (p=.69). CONCLUSION: Subcuticular incision and naturally sourced porcine collagen dermal filler appear to be efficacious for improving atrophic and rolling acne scars. Patients may prefer subcuticular incision over collagen dermal filler. Blinded evaluators found no significant difference between the treatments.

Relapse of acne following isotretinoin treatment: a retrospective study of 405 patients.

BACKGROUND: Isotretinoin is the most effective systemic treatment option for patients with nodulocystic acne or acne vulgaris who have failed a treatment with systemic antibiotics. METHODS: We conducted a retrospective study of 405 acne patients treated with isotretinoin to evaluate the incidence of recurrence after a course of at least 150 mg/kg of isotretinoin. RESULTS: Of the 405 patients evaluated, 94 (23.2%) experienced relapses severe enough for the patient to request further medical management. Of the 94 patients, 76 (80.9%) relapsed within the first 2 years following completion of a course of isotretinoin. LIMITATIONS: This was a retrospective study at a single practice site. CONCLUSION: Almost one-fifth of patients have a recurrence of acne within the first 2 years. Patients should be made aware of this information, as it will contribute to the development of accurate and appropriate expectations of therapy.

Actinomycetoma with negative culture: a therapeutic challenge.

Nocardia, Actinomyces, and Streptomyces species comprise the three broad classes of organisms that are causative for bacterial mycetoma. Although culture and molecular laboratory studies can usually identify the precise etiologic agent in bacterial mycetoma, occasionally these methods fail to clarify this situation. We report a classic clinical case of this infectious disease where usual diagnostic methods failed to identify the responsible organism, and discuss the empiric approach to such cases.