Tattoo removal using the alexandrite laser.

BACKGROUND: Until the recent development of the Q-switched lasers, it was not possible to remove tattoos without causing scarring, sometimes very disfiguring. Variations in wavelengths and pulse widths used may result in different clinical effectiveness or risks. The objective of this study was to determine the effectiveness of the alexandrite laser in removing professional and amateur tattoo pigment without adverse tissue response. RESULTS: We describe the clinical and histologic effects of the use of a new Q-switched laser for treatment of tattoos, the alexandrite laser (wavelength, 755 nm; pulse width, 100 nanoseconds). The results of treatment of 17 patients with professional tattoos and eight patients with amateur tattoos are analyzed. Greater than 95% removal of tattoo pigment averaged 8.9 treatment sessions. Transient hypopigmentation occurred in approximately 50% of patients, and transient textural surface changes occurred in 12%. CONCLUSIONS: The alexandrite laser is a safe and effective treatment modality for removal of black and blue-black tattoo pigment.

Pulsed carbon dioxide laser resurfacing of photo-aged facial skin.

BACKGROUND AND DESIGN: public demand for procedures to rejuvenate photoaged skin have stimulated the use of high-energy short-pulsed carbon dioxide lasers as a precise and predictable treatment modality. The purpose of this study was to determine the degree of clinical improvement achieved in treating perioral and periorbital wrinkles with a high-energy, microsecond-domain pulsed CO2 laser. Photodamaged skin in the perioral (n=73) and periorbital (n=38) regions was treated with multiple passes of confluent single pulses of CO2 laser energy (10 600 nm, 3-mm collimated beam, <1- millisecond pulse, 450 mJ per pulse, 2 to 5 W), with the tissue being cleansed and débrided with normal saline between passes. A nine-point clinical scoring system was devised for evaluation of the degree of wrinkling and photodamage present. Preoperative and postoperative photographs were independently scored by four ¿blinded¿ reviewers. The patients were observed postoperatively for 1 to 12 months for the course of healing, and adverse events were recorded. RESULTS: All three classes (mild, moderate, and severe) of photoaging of the skin responded equally well, showing an average wrinkling score reduction of 2.25 for the periorbital region and 2.34 for the perioral region, the most superficial wrinkles and photodamage being eliminated and the more severe being markedly improved. An unexpected finding was tightening of loose and folded skin. Side effects included transient erythemia and postinflammatory hyperpigmentation, and one instance of an isolated hypertrophic scar. CONCLUSIONS: Resurfacing of photoaged skin by means of a high-energy, microsecond-domain pulsed CO2 laser with a specific clinical treatment protocol results in predictable improvement in perioral and periorbital wrinkling and photodamage with minimal risks. Heat-induced collagen shrinkage appears to contribute to these results by tightening loose skin and folds.

Sclerosing agents in the treatment of telangiectasia. Comparison of the clinical and histologic effects of intravascular polidocanol, sodium tetradecyl sulfate, and hypertonic saline in the dorsal rabbit ear vein model.

A 0.25-mL quantity of 0.25%, 0.5%, and 1.0% polidocanol (Aethoxysclerol [France]), 0.5% sodium tetradecyl sulfate (Sotradecol injection), and 23.4% hypertonic saline was injected into the dorsal marginal rabbit ear vein; clinical and histologic thrombosis resulted that lasted between four and eight days. The lowest concentration of polidocanol (0.25%) demonstrated immediate thrombosis; however, no clinical or histologic changes occurred eight days after injection. With all other agents, histologic fibrosis of the vessel correlating with clinical disappearance occurred after eight days. However, 0.5% polidocanol and sodium tetradecyl sulfate developed recanalization through the initially sclerosed vessel between eight and 14 days, with clinical reappearance of the 0.5% polidocanol-injected vessel at 30 days, after injection. Cutaneous necrosis was noted clinically and histologically in three of ten vessels injected with 1.0% polidocanol and in two of ten vessels injected with hypertonic saline. Clinical and histologic evidence of necrosis occurred with and without extravasation of the sclerosants.

Treatment of leg veins with lasers and intense pulsed light. Preliminary considerations and a review of present technology.

Each laser system has different wavelengths, spot sizes, cooling mechanisms, and pulse durations. This article examines the advantages and disadvantages of different lasers with the proposition that, in the end, the best laser is the one that the practitioner can use best.

Advances in sclerotherapy.

Although venous systems are inherently variable, the treatment of varicose and telangiectatic leg veins can be approached in a logical, systematic fashion (Table 4). Instead of randomly injecting as many veins as possible in a given period of time, venous regions or entire abnormal superficial venous networks related to incompetent perforators should be injected in a single session. Although each patient requires differing amounts of time with this systematic approach, with experience, accurate estimations can be made, ensuring optimal productivity. Understanding the interconnected character of the venous system, it is senseless for physicians to limit treatment to telangiectatic veins. Dermatologists with an interest in phlebology should strive to perceive veins as a complete system, with the dermal telangiectatic component not as a separate skin disorder but as a manifestation of venous hypertension. An awareness of this will allow us to render optimal care for our patients.

Implementation and pharmacoeconomic analysis of a clinical staff pharmacist practice model.

The implementation and pharmacoeconomic analysis of a clinical staff pharmacist (CSP) practice model are described. Staff pharmacists at a large, tertiary care, academic medical center were selected and trained to perform clinical pharmacy services under the direction of clinical pharmacy specialist mentors. Clinical interventions by these CSP practitioners were evaluated in terms of direct cost savings (the difference in actual acquisition costs between therapies) and cost avoidance (the dollar value of adverse drug events [ADEs] avoided). The CSPs performed a total of 4959 interventions during a 12-month period. The interventions provided direct cost savings of $92,076 and an estimated cost avoidance of $488,436. Comparing cost savings and cost avoidance with the expenses of providing these services indicated a net economic benefit of $392,660. A new model of pharmacy practice that integrates staff pharmacists into existing clinical practice has the potential to minimize the risks, decrease the costs, and improve the outcomes associated with drug therapy.

The adjuvant use of macrophage colony stimulating factor in tattoo removal using laser surgery.

Tattoos are acquired pigmented lesions of the skin that may be removed with laser surgery. Following laser treatment, macrophages engulf the altered pigment. The activity of macrophages can be influenced by macrophage colony-stimulating factor. In order to evaluate the potential adjunctive use of macrophage colony-stimulating factor in tattoo removal using laser surgery, a prospective study, initially in an animal model, to serially evaluate the clinical and histopathologic clearing of tattoo pigment following laser surgery at variable macrophage colony-stimulating factor dose concentrations and injection schedules, could be performed. Since the clearing of tattoo pigment following laser surgery is influenced by the presence of macrophages at the site of treatment, and since macrophage colony-stimulating factor influences macrophage activity, it is logical to hypothesize that the adjuvant use of this cytokine to recruit additional macrophages could expedite the removal of tattoo pigment following laser surgery.

Laser treatment of erythematous/hypertrophic and pigmented scars in 26 patients.

Fifteen patients with erythematous/hypertrophic scars and 11 patients with postinflammatory hyperpigmentation were treated with a flashlamp pumped pulsed-dye laser at 585 nm or a flashlamp pulsed-dye laser at 510 nm. An average of 1.8 treatments resulted in an average improvement of 77 percent. Forty-seven percent of the patients had 100 percent improvement after one to three treatments. Eleven patients with postinflammatory hyperpigmentation were treated with the flashlamp pumped pulsed-dye laser at 510 nm with a pulse width of 300 ns. There was an average of 80 percent improvement with 1.45 treatments. Forty-five percent of the patients had 100 percent improvement after one or two treatments. The pathophysiology of postoperative scarring is reviewed. Theoretical reasons for the efficacy of laser treatment are detailed.

Treatment of poikiloderma of Civatte on the neck with an intense pulsed light source.

Effective treatment of poikiloderma of Civatte is difficult. The ideal treatment combines elimination of both the vascular and pigmented components simultaneously. Treatment with a broad-spectrum noncoherent intense pulsed light source delivers multiple wavelengths with software-controlled pulse durations and sequencing that permit treatment of both vascular and pigmented lesions simultaneously. The objective of this study was to determine the response and side effects of treating this condition with intense pulsed light. In the study, 66 patients with typical changes of poikiloderma of Civatte on the neck were treated with intense pulsed light at various settings every 4 weeks until the desired improvement occurred. A 50 to 75 percent improvement in the extent of telangiectasias and hyperpigmentation was observed after an average of 2.8 treatments. The incidence of hypopigmentation was 5 percent. It was concluded that intense pulsed light is an effective mode of therapy for poikiloderma of Civatte. It seems to offer a reduction in both pigmentation and telangiectasia-associated erythema, with minimal side effects.

Preoperative anesthesia and postoperative considerations in laser resurfacing.

This article details patient selection, preoperative preparation, and postoperative considerations for conducting UltraPulse (Coherent Medical, Palo Alto, CA) CO2 laser resurfacing. The authors share their more than 3 years experience with more than 1,000 patients to help physicians perform this technique, choose optimal treatment parameters, and select appropriate patients for treatment. Methods to decrease postlaser adverse sequelae are discussed. Particular emphasis is placed on the minimization of postoperative infections. An extensive section on anesthesia techniques is also provided.

The role of azithromycin and clarithromycin in clinical practice.

BACKGROUND: Azithromycin and clarithromycin are the newest approved macrolide antibiotics. OBJECTIVE: To review the pharmacology, microbiology, and clinical utility of these agents. SUMMARY: These agents have distinct advantages over erythromycin, including an improved pharmacokinetic profile, less toxicity, and a wider spectrum of activity. They are approved for the treatment of respiratory tract infections and uncomplicated skin and skin-structure infections associated with specific organisms. Azithromycin is also indicated for the treatment of nongonococcal urethritis. In addition, these agents may be useful in the treatment of toxoplasmosis, mycobacterial disease, Lyme disease, and legionellosis. Clarithromycin and azithromycin have lower rates of gastrointestinal side effects than erythromycin. CONCLUSIONS: Although clarithromycin and azithromycin show promise in the treatment of some less common infections, they should be considered alternatives to conventional agents in the treatment of respiratory tract, skin, and skin-structure infections caused by the usual pathogens. The expense of these agents may be prohibitive for routine use.

Antiviral agents for treating influenza.

The new neuraminidase inhibitors zanamivir and oseltamivir are important additions to the treatment of influenza, being the first class of agents active against both influenza A and influenza B. The decision to use these agents rather than amantadine or rimantadine, which are effective only against influenza A, should be based on the age of the patient, antiviral activity, side effect profile, ease of administration, drug interactions, and cost. All of these agents are effective only when started within 24 to 48 hours of onset of symptoms. To avoid inappropriate use of these agents, treatment should be continued only in patients with a confirmed diagnosis of influenza. Although effective in decreasing symptoms, none of these agents prevent pneumonia or hospitalization secondary to influenza.

Treatment of recalcitrant warts using the pulsed dye laser.

Recalcitrant warts are a common therapeutic problem. We used the 585 nm pulsed dye laser to treat flat, common, plantar/palmar, and periungual warts that had failed to respond to keratolytic or destructive therapy. Flat warts were most responsive, but all wart types had a significant response to this benign treatment modality.

CO2 laser resurfacing of the face and neck.

Laser resurfacing with the short-pulsed, high-energy CO2 laser has been used to treat photodamaged skin and acne scars. Efficacy and safety have been demonstrated with this technique since 1992. Newer treatment methods, including sequential or combination treatment with the Er:YAG laser have led to increased efficacy with a decrease in adverse sequelae. This article details the author's experience with CO2 laser resurfacing and promotes the use of sequential CO2/Er:YAG laser resurfacing.

Antibiotic prophylaxis in the critical care setting.

The prevention of infection in critically ill patients is a difficult and often frustrating task. Selective digestive decontamination may be a useful means of preventing infections in specific patient populations; however, not all critical care patients will benefit. In this article, mechanisms of antimicrobial resistance are discussed along with the consideration of specific measures to deal with this growing dilemma. Concerns about specific microorganisms, such as vancomycin-resistant enterococcus and multidrug-resistant Enterobacter species, are addressed. It is clear that the use of antimicrobial agents is not the only solution to the problem of infection in critically ill patients.

The current and future role of the nurse in phlebology: the Canadian experience.

Sclerotherapy treatment of varicose and telangiectatic leg veins is becoming a popular treatment in North America. Since the tools for performing this treatment are inexpensive and readily available, many health care practitioners are performing this technique with variable states of expertise and outcome. Understanding the professional and ethical issues facing phlebology nurses in Canada can enhance the care of phlebology patients in the United States.

Beneficial effect of a pharmacist refill evaluation clinic.

A study of 32 patients attending a pharmacist-run clinic was performed. This pharmacist refill evaluation clinic (PREC) assesses the continuation of maintenance drug therapy and is an alternative to the physician's clinic. This study evaluated total time spent at the clinic, reasons for refill requests, number of refills requested, number of requested refills approved, and number of physician consults and referrals required. The total clinic visit time at the PREC was 60 +/- 35.9 minutes versus a total time required at physicians clinic of 129 +/- 115.2 minutes. Of the patients treated at the PREC, 90.6% required no physician consult or referral. An estimated $135 savings in drug cost was approximated by the clinic during this small sample (a 30-day study), plus a difference in clinic fee that would amount to $1120 not including the difference in the pharmacist and physician's salaries. Other contributions attributed to this clinic were better patient compliance, accurate documentation of medication records, drug abuse surveillance, and drug therapy efficacy.

An investigation of side-effects and efficacy of foam-based sclerotherapy with carbon dioxide or room air in the treatment of reticular leg veins: a pilot study.

OBJECTIVES: In sclerotherapy, carbon dioxide (CO(2)) or room air can be employed by phlebologists for foam creation. We compared room air (RA) and carbon dioxide in treating reticular leg veins with foam sclerotherapy. METHODS: Twenty patients were randomly treated with RA- or CO(2)-created sodium tetradecyl sulphate (STS) foam. Concentration and volume of STS, side-effects and efficacy were determined. RESULTS: There was no difference in the efficacy, local side-effects or distant side-effects between RA and CO(2) foam in the treatment of reticular leg veins. The total volume of foam sclerosant required for treatment was greater with CO(2) compared with RA (P value = 0.01). CONCLUSION: No differences were found in efficacy or side-effects between RA- and CO(2)-foam sclerotherapy for reticular leg veins. CO(2) foam's shorter half-life was hypothesized to be responsible for larger total volumes of CO(2) foam sclerosant.

An investigation on the influence of glycerin on sclerosant foam stability.

BACKGROUND: Foam sclerotherapy is an increasingly popular modality in the treatment of varicose veins. Foam stability varies according to foam composition, volume and injection technique. MATERIALS AND METHODS: A disposable plastic connector was used to create foam from 0.50% sodium tetradecyl sulphate (STS) mixed with varying volumes of glycerin. As a measure of foam stability, the half liquid time was defined as the time required for half of the original volume of sclerosing solution to settle. Three recordings were determined for each of the three mixtures of sclerosant foam. RESULTS: The time for sclerosing solution to settle to half of its initial volume was found to be 89 seconds for 0.50% STS alone, 117.7 seconds with the addition of 0.1 mL of 72% glycerin, and 114.7 seconds with the addition of 0.2 mL of 72% glycerin. CONCLUSION: The small volumes of glycerin added to STS prolonged the half liquid time of STS foam up to 35%. As glycerin alone is unable to be foamed with the double-syringe system technique there may be a point at which further addition of glycerin has a negative effect on the half-life of foam.