A Description of Apixaban Dosing Patterns for Treatment or Prevention of Thrombotic Events in Hospitalized Patients on Dialysis.

Introduction: Apixaban is currently the only oral direct factor Xa inhibitor approved for treatment and prevention of venous thromboembolism (VTE) in patients on hemodialysis. Exclusion of dialysis patients from major clinical trials results in prescriber uncertainty regarding the optimal dose of apixaban for VTE treatment in this population. This study sought to characterize the variance in apixaban prescribing patterns for thrombotic indications other than atrial fibrillation. Methods: This retrospective, multi-center, descriptive study analyzed apixaban dosing patterns for hospitalized chronic dialysis patients with history of thrombosis. The primary outcome was incidence of deviation from manufacturer recommendations for dosing, assessed for either a new start or receipt prior to hospitalization. Secondary outcomes included observation of recurrent thrombotic and bleeding event rates during subsequent hospitalizations. Patients were analyzed into subgroups according to type of thrombotic indication for treatment. Data are reported with descriptive statistics. Results: A total of 101 patients were included. Deviations in recommended dosing were observed in 53 of 80 (66.2%) patients receiving apixaban for treatment of acute or chronic thrombosis. Of 44 patients started on apixaban during hospitalization for the indication of acute VTE, a dose deviation was observed in 79.5% of patients. Rates of rehospitalization for recurrent thrombotic events and bleeding were 11.8% and 9.9%, respectively. Conclusion: Variation in apixaban prescribing practices for the treatment of VTE in dialysis patients is common, suggesting an urgent need for prospective studies and updated dosing guidance to optimize safety with apixaban use in this population.

Particle Formation from Photooxidation of αpinene, Limonene, and Myrcene.

We present measurements of the effect of first-generation secondary organic aerosol (SOA) material on the growth of ∼10 nanometer diameter seed particles composed of sulfuric acid and water. Experiments were performed in an atmospheric pressure, vertically aligned flow reactor where OH was produced from HONO photolysis in the presence of either SO2 or a monoterpene. For typical conditions, organic compounds at ∼300 ppbv are exposed to photooxidation for a time of ∼80 s at a [OH] of about 6 × 106 cm-3: thus, oxidation products have minimal OH exposure. The measured size changes of the sulfuric acid seed particles can then be attributed to the uptake of first-generation products. Along with descriptions of the apparatus and the procedure, the analysis to obtain SOA yields by comparing them to growth with H2SO4(g) is detailed. Results from photooxidation experiments of αpinene, limonene, and myrcene give SOA yields of 0.040, 0.084, and 0.16, respectively. These SOA yields roughly double with each addition of a double bond to the compound. The αpinene and limonene results are in accord with the results of many previous SOA experiments, while the myrcene SOA yield stands alone. Photooxidation of myrcene also led to significant nucleation, and the species responsible is comparable to H2SO4 at a 35% relative humidity in its nucleation capability.

Comparison of blood cultures versus T2 Candida Panel in management of candidemia at a large community hospital.

The T2 Candida Panel (T2CP) has high sensitivity and specificity to detect candidemia. Its role in the diagnosis and management of candidemia compared to blood cultures (BC) remains unclear. The purpose of this study was to evaluate the T2CP versus BC in detecting and treating candidemia. A retrospective, observational cohort study was conducted to compare clinical outcomes in patients with candidemia identified by BC versus T2CP. Patients with a positive BC or T2CP for Candida spp. from January 2012 to August 2020 were grouped by initial method of detection (BC vs T2CP). Co-primary endpoints assessed included time to detection of candidemia and time to antifungal therapy. Key secondary endpoints included length of stay (LOS), ICU LOS, and mortality. One hundred sixty-three patients with a positive BC and 89 patients with a positive T2CP were included in the evaluation. The average time to detection of candidemia was significantly shorter in the T2CP group compared to BC group (9 vs 41 h, p < 0.001). The time to antifungal was also significantly shorter in the T2CP group compared to the BC group (4 vs 37 h, p < 0.001). However, LOS was significantly shorter in the BC positive group than the T2CP group with no difference in ICU LOS. There was no difference in in-hospital or 30-day mortality between the two groups. Of patients diagnosed with candidemia at our large community hospital, identification by T2CP led to faster detection and initiation of antifungal compared to blood cultures without improvement in LOS or mortality.

Patient-Targeted Googling by New Zealand Mental Health Professionals: A New Field of Ethical Consideration in the Internet Age.

BACKGROUND: Patient-targeted Googling (PTG) describes the searching on the Internet by healthcare professionals for information about patients with or without their knowledge. INTRODUCTION: Little research has been conducted into PTG internationally. PTG can have particular ethical implications within the field of mental health. This study was undertaken to identify the extent of PTG by New Zealand mental healthcare professionals and needs for further guidance regarding this issue. MATERIALS AND METHODS: All (1,850) psychiatrists, clinical psychologists, and psychotherapists working in New Zealand were electronically surveyed about their experience of PTG and knowledge about the associated practice of therapist-targeted Googling (TTG) using a questionnaire that had previously been developed with a German sample. Due to ethics and advertising restrictions, only one indirect approach was made to potential participants. RESULTS: Eighty-eight clinicians (5%) responded to the survey invitation. More than half (53.4%, N = 47) of respondents reportedly being engaged in PTG, but only a minority (10.3%, N = 9) had ever received any education about the subject. Reasons for undertaking PTG included facilitating the therapeutic process, information being in the public domain, and mitigating risks. Reasons against undertaking PTG included impairment of therapeutic relationship, unethical invasion of privacy, and concerns regarding the accuracy and clinical relevance of online information. Two-thirds of participants reported being the subject of TTG. DISCUSSION: New Zealand psychiatrists, clinical psychologists, and psychotherapists are engaging in PTG with limited education and professional guidance. Further discussion and research are required, and so, PTG is undertaken in a manner that is safe and useful for patients and health practitioners.

Prospective Patient-Related Outcome Evaluation of Secondary Cleft Rhinoplasty Using a Validated Questionnaire.

OBJECTIVE: To evaluate patient satisfaction and quality of life following secondary cleft rhinoplasty. DESIGN: Prospective consecutive patient, single unit, single surgeon study. SETTING: Spires Cleft Centre, Salisbury, Wilshire, United Kingdom, and private practice. PATIENTS, PARTICIPANTS: 56 (27 secondary cleft rhinoplasty) patients completed evaluation forms preoperatively and 3 to 6 months postoperatively. INTERVENTIONS: Subjective assessment was performed using a validated Rhinoplasty Outcomes Evaluation (ROE) questionnaire. This instrument comprises six questions that capture three quality-of-life domains: physical, mental/emotional, and social. MAIN OUTCOME: Rhinoplasty outcomes evaluation scores were calculated (range = 0 to 100) to indication satisfaction with rhinoplasty outcomes. RESULTS: Average age was 28 years (range = 18 to 59 years). There was a significant subjective improvement in the total ROE evaluation scores from 28 ± 10 to 80 ± 11 (P < .01) in secondary cleft rhinoplasty. Similar results were achieved in noncleft rhinoplasty 34 ± 9 to 84 ± 9 (P < .01). Specific scores for nasal aesthetic appearance improved from 0.3 ± 0.2 to 3.2 ± 0.3 (P < .01) in secondary cleft rhinoplasty. No significant change was seen in breathing capacity in secondary cleft rhinoplasty (from 2.7 ± 0.3 to 3.2 ± 0.2; P = .29). All patients said they would undergo the procedure again. CONCLUSION: Our results demonstrate high patient satisfaction after cleft rhinoplasty with particular regard to cosmetic appearance. These results are similar to those for noncleft rhinoplasty. We would recommend the use of this simple and quick validated outcome tool with all rhinoplasty patients.

Fidaxomicin Use and Clinical Outcomes for Clostridium difficile-Associated Diarrhea.

BACKGROUND: Fidaxomicin has been scrutinized because of its high acquisition cost. Real-world experience is needed to determine whether fidaxomicin has value in patients with Clostridium difficile-associated diarrhea (CDAD) and certain risk factors. METHODS: In this single-center, retrospective cohort study, patients 18 years or older with diarrheal symptoms and positive polymerase chain reaction assay for C. difficile toxin B gene or pseudomembranes were administered fidaxomicin between August 2011 and March 2013. Clinical success was defined as the resolution of signs and symptoms of disease and no further therapy required for CDAD as of the second day after cessation of fidaxomicin therapy. The recurrence of CDAD was defined by the reappearance of signs and symptoms of disease after the cessation of therapy, a new positive C. difficile polymerase chain reaction result, and the need for CDAD retreatment. Readmissions were tracked for 90 days after hospital discharge. RESULTS: Of the 60 patients who received fidaxomicin, 58 (96.7%) achieved clinical success. Twenty-six (43.3%) of the 60 patients were being treated for a second or greater episode. Six (10.3%) of the 58 patients had recurrence within 90 days after the initial treatment course, and 4 (6.9%) were readmitted within 30 days after hospital discharge. CONCLUSIONS: In this real-world setting, fidaxomicin resulted in a high rate of clinical success, a low rate of recurrence, and a low readmission rate.

Linezolid-induced lactic acidosis corrected with sustained low-efficiency dialysis: a case report.

Linezolid, an oxazolidinone antibiotic, has been reported to increase the risk of lactic acidosis and peripheral neuropathy because it disrupts mitochondrial function. This case report describes the development of lactic acidosis in a 63-year-old man who had received 3 months of treatment with intravenous linezolid for pulmonary nocardiasis, and correction of the acidotic state with sustained low-efficiency dialysis. This case demonstrates that renal replacement therapy can be an alternative to discontinuation alone for rapid reversal of linezolid-induced lactic acidosis.

Validation and Comparison of Nutrient Intakes from Two Dietary Questionnaires Developed for the Multiethnic Cohort Study.

BACKGROUND: Quantitative food frequency questionnaires (QFFQs) are often used to measure dietary intakes in large cohort studies but the impact of updating these questionnaires over time is not often examined. OBJECTIVE: This study compared nutrient intakes estimated from two different QFFQs to each other and to intakes calculated from three 24-hour dietary recalls (24HDRs). DESIGN: This study used a cross-sectional design. PARTICIPANTS/SETTING PARTICIPANTS: Participants (N = 352) were members of the Multiethnic Cohort Study from five racial and ethnic groups (African American, Japanese American, Latino American, Native Hawaiian, and White) who lived in Hawaii and Los Angeles. They were recruited in 2010 and asked to complete two QFFQs, two months apart, and three 24HDRs in the time between completion of the QFFQs. One questionnaire had been developed for a baseline survey (baseline QFFQ) at the start of the Multiethnic Cohort Study during 1993-1996, and the other was updated for a follow-up study 10 years later (10-year QFFQ). MAIN OUTCOME MEASURES: Daily intakes of energy and nine nutrients were estimated from both QFFQs, and from the average of three 24HDRs. STATISTICAL ANALYSES PERFORMED: Pearson's correlation coefficients were calculated between log-transformed nutrient intakes from each QFFQ and the 24HDRs and between the two QFFQs overall, by sex, and by race and ethnicity. RESULTS: Correlations for the 10-year QFFQ with the 24HDRs (average = 0.45) were higher than for the baseline QFFQ (average = 0.41), although the differences were not statistically significant. The increase in correlations was particularly pronounced for Native Hawaiian and African American participants. When absolute values were adjusted for energy intake, the average correlations were higher at 0.57 for the baseline QFFQ and 0.58 for the 10-year QFFQ overall and this pattern was seen in most racial and ethnic subgroups. The average correlations between the two QFFQs were 0.73 for both absolute intakes and nutrient densities overall. CONCLUSIONS: Correlations of nutrient intakes between the two QFFQs and 24HDRs were similar, and intakes from the two QFFQs were highly correlated. QFFQs updated for changes to the food supply may provide improved assessment for cohort studies that include diverse populations.

Multicenter Cohort Study of Ceftaroline Versus Daptomycin for Treatment of Methicillin-Resistant Staphylococcus aureus Bloodstream Infection.

BACKGROUND: Observational data suggest ceftaroline may be effective for methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI), but comparative data with standard of care are limited. This analysis compares the outcomes of MRSA BSI treated with ceftaroline or daptomycin. METHODS: Multicenter, retrospective, observational cohort study of adult patients with MRSA BSI from 2010 to 2017. Patients treated with ≥72 hours of ceftaroline or daptomycin were included. Those clearing BSI before study drug and those with a pneumonia source were excluded. The primary outcome was composite treatment failure, defined as 30-day mortality, BSI duration ≥7 days on study drug, and 60-day MRSA BSI recurrence. Inverse probability of treatment weighted risk difference in composite failure between daptomycin and ceftaroline groups was computed and 15% noninferiority margin applied. RESULTS: Two hundred seventy patients were included; 83 ceftaroline and 187 daptomycin. Ceftaroline was noninferior to daptomycin with respect to composite failure (39% daptomycin, 32.5% ceftaroline; weighted risk difference, 7.0% [95% confidence interval, -5.0% to 19.0%]). No differences between treatment groups was observed for 30-day mortality or other secondary efficacy outcomes. Creatine phosphokinase elevation was significantly more common among daptomycin patients (5.3% vs 0%, P = .034). Rash was significantly more common among ceftaroline patients (10.8 vs 1.1%, P = .001). CONCLUSIONS: No difference in treatment failure or mortality was observed between MRSA BSI treated with ceftaroline or daptomycin. These data support future study of ceftaroline as a primary MRSA BSI treatment and current use of ceftaroline when an alternative to vancomycin and daptomycin is required.

A bedside rescue method for retrieving retained guidewires: The 'Suck Out' technique.

BACKGROUND: Central venous catheter guidewire retention is classed as a 'never event' in the United Kingdom, with the potential for significant patient harm. If the retained guidewire remains within the central venous catheter lumen, bedside techniques may facilitate guidewire retrieval. However, these techniques may be ineffective if the guidewire has already passed below skin level. We investigated a novel 'suck out' technique for bedside guidewire retrieval and compared this against traditional retrieval methods. METHODS: Simulation 1: in a benchtop model, seven different central venous catheters had their corresponding guidewire placed in the last 2 cm of the catheter tip which was immersed horizontally in fluid. A 50-mL syringe was attached to the distal lumen central venous catheter hub and suction applied for 5 s, and the distance of guidewire retraction was recorded. Simulation 2: a central venous catheter guidewire was intentionally retained within the catheter at either 5 cm above or below skin level in a pigskin model. Simple catheter withdrawal, catheter clamping withdrawal and the 'suck out' method were compared for efficacy using Fisher's exact test. RESULTS: Simulation 1: retained guidewires were retracted by 13 cm on average. Simulation 2: when guidewires were retained 5 cm above skin level, all retrieval methods were 100% effective; however, when retained 5 cm below skin level, simple catheter withdrawal was ineffective, clamping and withdrawal was only 10% effective and the 'suck out' technique was 90% effective (p < 0.001). CONCLUSION: The 'suck out' technique can effectively retract guidewires retained within central venous catheter lumens and demonstrates superiority over traditional methods of retained guidewire extraction in simulated models.

Utilization and impact of a rapid Candida panel on antifungal stewardship program within a large community hospital.

BACKGROUND: The T2 Candida Panel (T2CP) bodes high sensitivity and specificity to detect candidemia, enabling providers to make quick therapy decisions and possibly decrease mortality. However, utilization in practice and clinical application remains to be evaluated. OBJECTIVES: To evaluate the overall provider-utilization of the T2CP at a large community hospital. METHODS: This single center, retrospective, observational study compared antifungal management in all patients with positive or negative T2CP. Additional endpoints included patient-specific variables influencing antifungal management decisions. RESULTS: Six hundred twenty-eight T2CP results were evaluated. Antifungal optimization occurred in 54% of patients who had antifungal orders at the time of T2CP test. Antifungal therapy was avoided in 60.4% of negative cases. Patients with negative T2CP had significantly fewer days of therapy compared to positive tests. CONCLUSIONS: Although the T2CP led to fewer days of antifungal therapy with negative tests, many opportunities for improvement in antifungal stewardship were identified, specifically, with negative tests.

Assessment of the reproducibility of facial expressions with 3-D stereophotogrammetry.

OBJECTIVE: There is little research into analyzing whether facial expression changes are secondary to actual treatment or normal day-to-day variation. This study aims to ascertain whether nine-facial expressions were reproducible. SUBJECTS AND METHODS: Thirty-nine white subjects performed nine-facial expressions, captured by three-dimensional stereophotogrammetry in three sessions. After initial capture (session 1), each expression was repeated after 15 minutes (session 2) and then 4 weeks (session 3) after the initial session. Statistical analysis was performed on the mean variability of facial landmarks between session 1 and 2 and session 1 and 3. RESULTS: Repose was the most reproducible expression. The least reproducible was "blow-out-the-cheeks." Analysis between session 1 and 2 showed no significant differences in expression reproducibility. Analysis between session 1 and 3 showed significant differences for the "smile-with-lips-open" and "blow-out-the-cheeks" expressions. CONCLUSION: Facial expressions are reproducible in a 15-minute period. There are significant differences in the ability to reproduce facial expressions 4 weeks apart for "smile-with-lips-open" and "blow-out-the-cheeks."

3D stereophotogrammetry quantitative lip analysis.

BACKGROUND: Reduction in lip volume is a stigmata of the aging face. There are many lip augmentation techniques but very few studies analyzing how these techniques change the three-dimensional structure of the lips. Furthermore, there is no consensus about whether the lip position should be standardized to either the lips closed or parted. The aim of this study was first to obtain a three-dimensional quantitative analysis of the lips in adults and to look for sexual dimorphism and, second, to compare whether more consistent measurements of the oral region can be obtained with the mouth open compared with it closed. METHODS: Seventy young Caucasian volunteers underwent lip dimension analysis using 3D stereophotogrammetry with lips parted and closed. Parameters measured for consistency of results were linear distances (e.g., mouth width, total lip height, upper lip height), surface distances (e.g., upper vermilion), areas (e.g., vermilion upper and lower lip, total vermilion), and volumes (upper and lower lip volume, total lip volume). Analysis also compared lip dimensions between male and female subjects. RESULTS: Consistent and reproducible results were seen with the lips closed compared with lips apart. All lip parameters (distances, areas, and volumes) were larger in men than in women. The following measurements had significant differences between males and females: mouth width, upper lip height median, upper white lip height median, upper white lip height lateral, lower vermilion surface distance, and area of vermilion (p < 0.05). CONCLUSION: We present a novel technique for aesthetic assessment of the lips that is objective and achieves consistency with the lips in the closed position. Males have greater lip dimensions compared with females.

Physical and in silico approaches identify DNA-PK in a Tax DNA-damage response interactome.

BACKGROUND: We have initiated an effort to exhaustively map interactions between HTLV-1 Tax and host cellular proteins. The resulting Tax interactome will have significant utility toward defining new and understanding known activities of this important viral protein. In addition, the completion of a full Tax interactome will also help shed light upon the functional consequences of these myriad Tax activities. The physical mapping process involved the affinity isolation of Tax complexes followed by sequence identification using tandem mass spectrometry. To date we have mapped 250 cellular components within this interactome. Here we present our approach to prioritizing these interactions via an in silico culling process. RESULTS: We first constructed an in silico Tax interactome comprised of 46 literature-confirmed protein-protein interactions. This number was then reduced to four Tax-interactions suspected to play a role in DNA damage response (Rad51, TOP1, Chk2, 53BP1). The first-neighbor and second-neighbor interactions of these four proteins were assembled from available human protein interaction databases. Through an analysis of betweenness and closeness centrality measures, and numbers of interactions, we ranked proteins in the first neighborhood. When this rank list was compared to the list of physical Tax-binding proteins, DNA-PK was the highest ranked protein common to both lists. An overlapping clustering of the Tax-specific second-neighborhood protein network showed DNA-PK to be one of three bridge proteins that link multiple clusters in the DNA damage response network. CONCLUSION: The interaction of Tax with DNA-PK represents an important biological paradigm as suggested via consensus findings in vivo and in silico. We present this methodology as an approach to discovery and as a means of validating components of a consensus Tax interactome.

Feasibility and Conceptualization of an e-Mental Health Treatment for Depression in Older Adults: Mixed-Methods Study.

BACKGROUND: Depression is one of the most common mental disorders in older adults. Unfortunately, it often goes unrecognized in the older population. OBJECTIVE: The aim of this study was to identify how Web-based apps can recognize and help treat depression in older adults. METHODS: Focus groups were conducted with mental health care experts. A Web-based survey of 56 older adults suffering from depression was conducted. Qualitative interviews were conducted with 2 individuals. RESULTS: Results of the focus groups highlighted that there is a need for a collaborative care platform for depression in old age. Findings from the Web-based study showed that younger participants (aged 50 to 64 years) used electronic media more often than older participants (aged 65 years and older). The interviews pointed in a comparable direction. CONCLUSIONS: Overall, an e-mental (electronic mental) health treatment for depression in older adults would be well accepted. Web-based care platforms should be developed, evaluated, and in case of evidence for their effectiveness, integrated into the everyday clinic.

A Comparative Study of the Aesthetic Outcome of Two Techniques for Unilateral Complete Cleft Lip Repair.

BACKGROUND: Cleft lip repair aims to create symmetric nasolabial morphology with minimal scarring. Poor aesthetic outcomes may have damaging psychosocial implications. Determining the optimal method of recreating lip symmetry is a major goal of applied cleft clinical research. This study aims to determine whether subjective assessment could differentiate aesthetic outcome between two surgeons who use two different surgical techniques for unilateral cleft lip repair. METHODS: Surgeon A uses a modified rotation-advancement technique incorporating a supra-white roll flap and Noordhoff-style vermilion flap. Surgeon B uses an upper and lower triangle technique. Neither surgeon used presurgical orthopedics. Five-year postoperative frontal photographs (cropped according to the Asher-McDade aesthetic index) were analyzed by a panel of 40 blinded surgical and lay reviewers using a five-point Likert scale. The assessments were repeated after a 2-week interval to assess intrarater reliability. RESULTS: Thirty-nine consecutive complete unilateral cleft lip and palate patients were assessed for each surgeon. The mean Likert score for surgical/lay assessors was 3.07/3.00 for surgeon A and 2.67/2.61 for surgeon B. This difference was statistically significant (p < 0.05). The interrater reliability was excellent and the intrarater reliability was fair. There was good correlation between lay and surgical assessors. CONCLUSION: Subjective assessment of clinical photography provides a reliable method of differentiating aesthetic outcome after unilateral cleft lip repair and presents a rapid and straightforward clinically relevant method of comparing surgical outcomes.

Do Patients Look Up Their Therapists Online? An Exploratory Study Among Patients in Psychotherapy.

BACKGROUND: The use of the Internet as a source of health information is growing among people who experience mental health difficulties. The increase in Internet use has led to questions about online information-seeking behaviors, for example, how psychotherapists and patients use the Internet to ascertain information about each other. The notion of psychotherapists seeking information about their patients online (patient-targeted googling, PTG) has been identified and explored. However, the idea of patients searching for information online about their psychotherapists (therapist-targeted googling, TTG) and the associated motives and effects on the therapeutic relationship remain unclear. OBJECTIVE: This study investigated former and current German-speaking psychotherapy patients' behavior and attitudes relating to TTG. In addition, patients' methods of information gathering, motives, and success in searching for information were examined. Furthermore, patients' experiences and perceptions of PTG were explored. METHODS: Overall, 238 former and current psychotherapy patients responded to a new questionnaire specifically designed to assess the frequency, motives, use, and outcomes of TTG as well as experiences and perceptions of PTG. The study sample was a nonrepresentative convenience sample recruited online via several German-speaking therapy platforms and self-help forums. RESULTS: Of the 238 former and current patients who responded, 106 (44.5%) had obtained information about their therapists; most of them (n=85, 80.2%) had used the Internet for this. Besides curiosity, motives behind information searches included the desire to get to know the therapist better by attempting to search for both professional and private information. TTG appeared to be associated with phases of therapy in which patients felt that progress was not being made. Patients being treated for personality disorders appear to engage more frequently in TTG (rphi = 0.21; P=.004). In general, however, information about therapists sought for online was often not found. Furthermore, most patients refrained from telling their therapist about their information searches. CONCLUSIONS: Patients appear to engage in TTG to obtain both professional and private information about their psychotherapists. TTG can be viewed as a form of client-initiated disclosure. It is therefore important to include TTG as a subject in therapists' education and also to raise awareness within patient education. This investigation provides the first findings into TTG to begin debate on this subject.

Lasers and ancillary treatments for scar management: personal experience over two decades and contextual review of the literature. Part I: Burn scars.

The formation of a wide range of excessive scars following various skin injuries is a natural consequence of healing. Scars resulting from surgery or trauma affect approximately 100 million people per annum in the developed world and can have profound physical, aesthetic, psychological and social consequences. Thus, scar treatment is a priority for the plastic surgeon. We aim to explore new approaches to the management of such scarring. The senior authors current use of laser technology, chemotherapeutic agents, pharmacotherapy and cryosurgery will be reviewed. This is placed in the context of the current literature and evidence base and is illustrated with case studies, starting with burns scars in part I, and focusing on keloid and hypertrophic scars in part II, acne scars in part III and finally pigmented scars in part IV. In Part I we focus on burns scar treatment with fractional ablative 10,600 nm wavelength carbon dioxide (CO2) laser therapy.

Training in bilateral breast reduction and breast augmentation: the results of a supra-regional audit.

INTRODUCTION: Bilateral breast reduction (BBR) and bilateral breast augmentation (BBA) represent ideal training procedures. This study prospectively audited BBR and BBA training opportunities at six plastic surgery units. METHODS: Operative numbers and training opportunities were audited at 6 plastic surgical units in the south west region. RESULTS: The results demonstrated considerable variations in training opportunities between different hospitals. In some cases, trainees did not operate on a single BBR or BBA, despite relatively high overall operative numbers. These differences did not relate to trainee seniority or patient demographics. CONCLUSION: The variations and deficiencies in training opportunities identified in this study may be due to a number of factors, such as local attitudes to training, external pressure on operative lists and the EWTD restrictions. These findings are unlikely to be confined to one region and should encourage wider audit of training provision.