Appreciation of the Vascular Anatomy of Aesthetic Forehead Reflation.

BACKGROUND: Worldwide, the brow is the most common facial site to receive aesthetic treatment. However, the forehead above the brows has been comparatively less well studied with respect to both neuromodulators and fillers. Age-related remodeling of the forehead with loss of facial bone has been demonstrated on detailed radiographic studies. Concurrent loss of facial fat deposits also adds to the volume depletion. The resulting shallow scalloped depressions in the central 2/3 of the forehead give a tired and aged appearance as do the deep etched horizontal forehead lines which are often associated. Temporal hollowing may be an important associated feature. METHODS: Combination treatment of the upper face with neuromodulators to elevate the brows and diluted hyaluronic acid (HA) fillers to smooth the medial glabellar complex and reflate the forehead and temple has recently become a desired and popular treatment. Several techniques have been described in the literature. All these techniques are designed to allow forehead reflation with reduction of the possibility of vascular compromise. CONCLUSION: Avoidance of the supratrochlear and supraorbital vasculature with cosmetic filler injections is possible by insertion of needle or cannula into the subgaleal space above their transition from preperiosteal to subcutaneous level. Using this technique we have so far not seen any vascular compromise and we present this technique in the interest of patient safety.

Temporal associations between individual changes in hormones, training motivation and physical performance in elite and non-elite trained men.

To advance our understanding of the hormonal contribution to athletic performance, we examined the temporal associations between individual changes in testosterone (T) and/or cortisol (C) concentrations, training motivation and physical performance in elite and non-elite trained men. Two male cohorts classified as elites (n = 12) and non-elites (n = 12) completed five testing sessions over a six-week period. The athletes were tested for salivary T, C, T/C ratio, self-perceived training motivation, countermovement jump (CMJ) height and isometric mid-thigh pull peak force (IMTP PF), after which an actual training workout was performed. The elite men reported higher motivation to train and they produced greater CMJ height overall, whereas the non-elites had higher pooled T levels (p < 0.05). No significant group differences in C concentrations, T/C ratio or IMTP PF were found. The individual changes in T levels were positively associated with training motivation in the elite men only (p = 0.033), but the hormonal and motivation measures did not predict CMJ height or IMTP PF in either group. The monitoring of elite and non-elite men across a short training block revealed differences in T levels, motivation and lower-body power, which may reflect training and competitive factors in each group. Despite having lower T levels, the elite athletes showed better linkage between pre-training T fluctuations and subsequent motivation to train. The nature of the performance tests (i.e. single repetition trials) could partly explain the lack of an association with the hormonal and motivational measures.

Translation of tobacco control programs in schools: findings from a rapid review of systematic reviews of implementation and dissemination interventions.

ISSUE ADDRESSED: School-based programs targeting the prevention of tobacco use are a key strategy for reducing the overall tobacco-related mortality and morbidity in the community. While substantial research investment has resulted in the identification of various effective tobacco prevention interventions in schools, this research investment will not result in public health benefits, unless effectively disseminated and implemented. This rapid review aimed to identify effective implementation or dissemination interventions, targeting the adoption of school-based tobacco prevention programs. METHODS: A systematic search was conducted to identify published systematic reviews that examined the effectiveness of implementation and dissemination strategies for facilitating the adoption of tobacco policies or programs in schools from 1992 to 2012. RESULTS: The search yielded 1028 results, with one relevant systematic review being identified. The review included two controlled studies examining the implementation and dissemination of tobacco prevention programs and guidelines. The two randomised trials examined the delivery of active face-to-face training to implement a school-based curriculum compared with video-delivered or mail-based training. Improvements in the implementation of the programs were reported for the face-to-face training arm in both trials. CONCLUSIONS: Little rigorous evidence exists to guide the implementation and dissemination of tobacco prevention programs in schools. SO WHAT? Few systematic reviews exist to inform the implementation of evidence-based tobacco prevention programs in schools. In the absence of a strong evidence base, health care policymakers and practitioners may need to draw on setting-based frameworks or parallel evidence from other settings to design strategies to facilitate the adoption of tobacco prevention initiatives.

Safety of lidocaine 15% and prilocaine 5% topical ointment used as local anesthesia for intense pulsed light treatment.

BACKGROUND: Literature cautions against applying lidocaine 15%/prilocaine 5% over an area larger than 300 cm(2). The area of the face, neck, and chest is 400 cm(2) or greater. OBJECTIVE: To investigate the safety of lidocaine 15%/prilocaine 5% topical anesthetic ointment used as anesthesia for intense pulsed light (IPL) treatment. METHODS AND MATERIALS: Lidocaine 15%/prilocaine 5% ointment was applied to the face only (n=10) for 30 +/- 15 minutes or to the face, neck, and chest (n=10) for a total of 60 +/- 15 minutes before IPL. Blood lidocaine and prilocaine levels were measured. Adverse events were recorded. RESULTS: For the entire cohort, blood was drawn 25.6 +/- 6.6 minutes after IPL was completed. In the face only group, the mean lidocaine level was 0.122 +/- 0.125 microg/mL, and the mean prilocaine level was 0.048 +/- 0.029 microg/mL. In the face, neck, and chest group, the mean lidocaine level was 0.272 +/- 0.208 microg/mL, and the mean prilocaine level was 0.087 +/- 0.060 microg/mL. No adverse events related to systemic toxicity were observed or reported to the nurse. At the 24-hour follow-up, no subject reported symptoms of systemic toxicity after leaving the clinic. CONCLUSION: Under the conditions of this study, topical lidocaine 15%/prilocaine 5% produces low levels of systemic absorption.

Botulinum toxin products overview.

The tremendous success of botulinum toxin type A (BOTOX(R), Allergan Inc.) in the cosmetic arena has acted as a stimulus for the development of other neurotoxins. After more than 2 decades of use, BOTOX(R) has become synonymous with wrinkle reduction and is considered to be the one of the most common non-surgical cosmetic procedures performed worldwide. Because of its vast popularity among patients seeking non-invasive methods to achieve facial rejuvenation, physicians from diverse specialties have integrated botulinum toxin injections into their existing practices. Herein, we present an overview of botulinum toxin products for cosmetic applications that have received regulatory approval or are under development.

Clinical Use of RESTYLANE.

There is no ideal filler, nor will there be a single product that can satisfy all requirements. However, RESTYLANE, a non-animal, stabilized hyaluronic acid (NASHA, Medicis), is a very versatile augmenting agent. It has been in clinical use for 8 years and experience has shown it to be close to the ideal filler in many respects. This review will outline the background to the use of RESTYLANE, and will focus on the clinical use of this material.

Papillary and follicular thyroid cancer. Prognostic factors in 1,578 patients.

This report from the Canadian survey of thyroid cancer describes 1,074 patients with papillary thyroid cancer and 504 with follicular thyroid cancer followed for four to 24 years. The study groups included more patients with "advanced" disease and fewer with "early" disease than in the general population because these patients were referred to radiotherapy cancer centers, sometimes routinely, but often because referring physicians believed that certain clinical features indicated the need for additional treatment. Although this report is subject to all the problems of retrospective studies, a careful assessment of the pretreatment extent of disease combined with a long follow-up period has allowed an analysis of prognostic factors with considerable confidence. Univariate analysis of 12 possible prognostic factors (excluding treatment) demonstrated that nine of them were of statistical significance: postoperative status, age at diagnosis, extrathyroidal invasion, distant metastases, nodal involvement, differentiation, sex, tumor size, and pathologic type (in descending order of importance). Multivariate analysis was carried out using cause-specific survival rates. Independently important prognostic factors at initial treatment were age at diagnosis, extrathyroidal invasion, and degree of differentiation histologically for papillary cancers; and extrathyroidal invasion, distant metastases, primary tumor size, nodal involvement, age at diagnosis, and postoperative status for follicular cancers. The prognostic factors for tumor recurrence were quite different for the papillary and follicular cancers and ranked differently for the two groups.

Papillary and follicular thyroid cancer: impact of treatment in 1578 patients.

We report the experience from 13 Canadian radiotherapy centres concerning the treatment and outcome for 1074 papillary and 504 follicular thyroid cancer patients followed for 4-24 years. Surgical resection was carried out in almost all patients; there was no correlation between the type of operation and recurrence or survival. Treatment with external irradiation (201 patients) radioiodine (214 patients), or both (107 patients) was used more often in poor prognosis patients than in those with good prognostic factors, and was effective in reducing local recurrences and improving survival, especially in patients with microscopic residual disease postoperatively. Treatment complications were common but rarely fatal. Thyroid cancer was the cause of death in over half of the papillary cancer deaths and in two-thirds of the follicular cancer deaths.

Botulinum vs adjustable suture surgery in the treatment of horizontal misalignment in adult patients lacking fusion.

Thirty patients were treated with either botulinum toxin or adjustable suture surgery in a prospective, randomized clinical trial. All patients had horizontal deviations greater than 10 prism diopters and absent fusion. Seventeen patients were assigned to toxin treatment, and 13 were assigned to surgical treatment. Follow-up at 6 months after either procedure indicated that surgery was superior, with patient alignment showing a 92.7% average net change, compared with a 50.50% net change in the botulinum-treated group. There was no difference in response between those patients with a starting deviation of 20 PD or less and greater than 20 PD in the surgery group. However, in the botulinum-treated group, those patients with a starting deviation of 20 PD or less seemed to show better responses than those patients with greater than 20 PD. Patients with esotropia showed an 88.89% change with surgery and a 51.55% change with toxin treatment. Patients with exotropia had a 95.83% change with surgery but a 50.3% change with toxin treatment. Since we had 20 patients with exotropia and 10 patients with esotropia, a more formal comparison would require larger numbers.

Quantitative analysis of trace elements in human blood and plasma by energy dispersive X-ray fluorescence.

A photon excitation, secondary target x-ray fluorescence system was used to measure concentrations of Cu, Zn, Br and Rb in whole blood and plasma of healthy adults. The samples preparation method and calculated limits of detection of the technique are reported. Correlation statistics for elemental concentrations have been determined. Verification of the results for copper was performed using atomic absorption spectrophotometry.

A pilot study of children with amblyopia treated by the gratings method.

A total of 6 patients, 2 with anisometropic, 2 with strabismic and anisometropic, and 2 with strabismic amblyopia treated with the 'gratings method' showed more than 2 lines of improvement in linear visual acuity. Patient attention and interest and repeated testing of the visual acuity were uncontrolled factors in this study. Moreover, the detailed visual tasks performed by the amblyopic eye may in themselves be the reason for improvement. Clearly a careful study which controls these possibilities is needed before a claim can be made that the 'gratings' per se offer an improved method of treatment of amblyopia.

Metarhodopsin III formation and decay kinetics: comparison of bovine and human rhodopsin.

Absorbance spectra were recorded at various times after photolysis of hypotonically washed membrane suspensions of human and bovine rhodopsin (pH 7 or 8, T = 20 or 37 degrees C). Global data analysis showed that at 20 degrees C, metarhodopsin III formation was the only process occurring from 1 to 30 min following photolysis. At pH 8, a significant amount of human metarhodopsin I was present before metarhodopsin III formed. At 37 degrees C, two decay processes were seen, formation of metarhodopsin III (lifetime 113 +/- 3 sec bovine, 93 +/- 2 sec human) and formation of a species with the properties of n-retinylidine opsin (lifetime 900 +/- 150 sec bovine, 2000 +/- 350 sec human). A larger fraction of human rhodopsin (approximately 50%) is converted to metarhodopsin III than is the case for bovine rhodopsin (approximately 35%).

Squamous cell carcinoma of the thyroid gland.

We present the clinical manifestations and details of treatment and outcome for eight patients with squamous cell cancer arising in the thyroid gland, which is a rare entity. All patients had advanced disease, with primary tumors invading adjacent structures (the trachea, esophagus, and major vessels). In two patients, pulmonary metastases were also present. Six patients died 6 months or less after diagnosis, five from the effects of local disease. Transient palliation was obtained in four patients who underwent partial excision (three patients) and radical radiotherapy (one patient). Two patients remained free of disease at last follow-up more than 4 years after gross total tumor resection and radical radiotherapy and were presumably cured. One patient treated by partial resection and radical radiotherapy died from other causes 17 months later. His disease status was unknown. Complete excision with postoperative radiotherapy may be curative, and debulking followed by external irradiation may provide short-term palliation. Patients with unresectable tumors are best managed by supportive measures only unless a truly effective chemotherapeutic regimen is developed for squamous cell cancer of the head and neck.

The role of external radiation in the management of papillary and follicular thyroid cancer.

Review of 137 patients with differentiated thryroid carcinoma (82 papillary and 55 follicular) demonstrates that external radiation in moderate dosage eradicates microscopic disease. Its use could lead to a decrease in surgical complications by avoiding unnecessarily radical attempts at removing all potential microscopic disease. Gross tumor also responds favorably to external radiation, but its very slow regression rate has led to the misconception that external radiation is ineffective in the treatment of these cancers. Both radioiodine and thyroid hormone play an important role in the management of differentiated thyroid cancers, but their effectiveness should not be overestimated.

Pan-Thames survey of occupational exposure to HIV and the use of post-exposure prophylaxis in 71 NHS trusts.

OBJECTIVES: To review the management of occupational exposure to definite or suspected HIV-infected blood, following the introduction of the 1997 UK Department of Health guidelines on the use of post-exposure prophylaxis. METHODS: Cross-sectional telephone survey of protocols in 71 NHS Trusts in the Pan-Thames region. Retrospective postal survey of the management of each definite or suspected HIV blood exposure between 1 July 1997 and 30 June 1999. RESULTS: Sixty-two (93%) Trusts had a written protocol, with many specialties involved in exposure management. Twenty-four Trusts reported 171 occupational exposures to definite or suspected HIV-infected blood. Of 97 definite HIV exposures, eight (8%) were discovered on post-incident HIV testing of the source patient; to which most source patients agreed when approached. Seventy-two (74%) exposed health care workers started prophylaxis and 49 (68%) completed the recommended 4-week course. Only half of those whose exposures occurred more than 6 months ago were known to have had a follow-up HIV test. CONCLUSIONS: Although most Trusts have implemented the Department of Health's guidance, collecting data on individual exposures proved difficult. We suggest that a designated department in each Trust co-ordinates and records HIV exposure management. Routine HIV testing is acceptable to most source patients and is appropriate in areas with a high prevalence of HIV seropositivity.

Botulinum toxin for benign essential blepharospasm, hemifacial spasm and age-related lower eyelid entropion.

Purified botulinum A exotoxin was used in the treatment of forty seven patients with benign essential blepharospasm, 11 patients with hemifacial spasm and 2 patients with age-related entropion. The treatment was effective in all three groups for an average of 3-4 months when symptoms recurred and repeated chemodenervation with toxin was needed. The commonest complication was transient ptosis with an overall frequency of 7.8%. This incidence increased to 11.1% with toxin doses higher than 25 units per orbicularis. The treatment was well accepted by the patients, who were subsequently able to return to pre-blepharospasm lifestyles.

Neurodevelopmental criteria in the classification of congenital motor nystagmus.

Congenital motor nystagmus (CMN) can be familial or non-familial. The expressivity of CMN is so variable that in one affected member of the family the oscillations are obvious, while in the others the nystagmus could be overlooked even by the patients themselves. In spontaneous cases the proof of heredity might be discovered by an ophthalmological examination or eye movement recordings of other family members. Our multidisciplinary studies of 27 children with CMN suggests that a neurodevelopmental assessment can also be valuable in establishing a diagnosis of heredity. Our studies suggest that the hereditary form of CMN is free from neurodevelopmental problems, while the non-familial form is not. Therefore, children with spontaneous CMN could be referred for neurodevelopmental evaluation in order to establish a more accurate diagnosis.

A pilot study on the use of botulinum toxin in spasmodic torticollis.

Dystonic torticollis has been treated with local injections of botulinum toxin in a single blind study of 12 patients. A significant decrease of abnormal movements was recorded, and pain improved. Further studies are desirable to define the optimum dosage and site for injections, and the long term effects of repeated injections.