Wound Debridement in Pyoderma Gangrenosum.

BACKGROUND: Wound debridement improves healing in a variety of acute and chronic ulcers. However, there is concern that debridement may trigger pathergy and worsen pyoderma gangrenosum (PG). OBJECTIVE: To determine whether published evidence supports conservative wound debridement for PG. DATA SOURCES: The authors reviewed the literature published in MEDLINE through January 2023 using the search germs "pyoderma gangrenosum" and "debridement." STUDY SELECTION: Articles reporting sharp surgical debridement or maggot debridement for PG were included in the review. The authors also searched the reference sections of the reviewed articles for additional reports on debridement for PG. DATA EXTRACTION: Clinical data regarding patient status, procedures performed, and patient outcomes were extracted from the selected articles. DATA SYNTHESIS: There are multiple reports of uncontrolled, active-phase PG wounds worsening after aggressive excisional debridement of viable inflamed tissues. In contrast, there is no evidence indicating that conservative debridement of nonviable necrotic tissue worsens PG wounds, regardless of the disease activity. There are multiple reports of successful debridement and surgical grafting for PG in remission. CONCLUSIONS: There is no evidence in favor of or against using conservative debridement of nonviable necrotic tissue for a PG wound. Therefore, it should not be considered contraindicated, even in the active phase of the disease.

Intravitreal bevacizumab injection in aggressive posterior retinopathy of prematurity compared with type I retinopathy of prematurity.

PURPOSE: To compare type I retinopathy of prematurity (ROP) with aggressive posterior retinopathy of prematurity (AP-ROP) regarding risk factors, complications and treatment outcomes. METHODS: A prospective cohort approach was applied on premature newborns diagnosed as type I ROP and AP-ROP. An intravitreal injection of bevacizumab (Avastin®) was given to each patient. Demographic features such as gestational age, birth weight, age at the initial injection, involved eye, treatment response, relapses and need to extra interventions were compared. RESULTS: Seventy-seven patients underwent an initial intravitreal injection of bevacizumab (IVB), and 108 eyes were type I ROP and 30 eyes were AP-ROP. There was no significant difference in birth weight and gestational age between two groups. ROP relapsed in eight eyes of four patients with AP-ROP (26.6%), of which six eyes of three patients received re-injection of bevacizumab, and two eyes of one patient underwent a laser treatment. Recurrence occurred in two eyes of one patient with type I ROP (1.8%), which were treated by laser. CONCLUSION: Bilateral eye involvement, relapse and retreatment (IVB, laser and surgical intervention) are more frequent in AP-ROP than type I ROP even when treated with intravitreal bevacizumab injection.

Controlling depth of electrosurgery after curettage of skin tumors-an in vitro study.

BACKGROUND: Depth of tissue injury in electrosurgery depends on generator power, electrode size, speed of electrode movement on tissue, and current delivery method. We sought to evaluate the depth of tissue injury associated with different methods of electrocoagulation in an effort to make electrocoagulation more reproducible. METHODS: A knife-shaped electrode was used to apply an electrosurgical current to the surface of a piece of bovine liver. Different electrosurgical methods were performed. Cross sections of the liver were then studied for tissue effect. RESULTS: Fulguration provided only superficial coagulation. Contact electrocoagulation and electrodesiccation using the flat side of the electrode provided significantly deeper levels of coagulation and were associated with less smoke than fulguration. Desiccation provided the deepest tissue effect. CONCLUSIONS: Electrofulguration can be used for superficial tissue destruction. For deeper coagulation, a relatively larger electrode can be used in contact mode. Slower movement of the electrode on tissue in contact mode is associated with desiccation and the deepest level of tissue destruction.

Management of fluid status and cardiovascular function in patients with diffuse skin inflammation.

Background: Skin inflammation causes vasodilation and increased vascular permeability, which may result in decreased blood pressure and peripheral edema. Patients with erythroderma usually compensate for low blood pressure with fluid retention and increased cardiac output. However, if the heart cannot support increased cardiac output, blood pressure will stay low, resulting in severe compensatory fluid retention, which leads to decompensated congestive heart failure, and pulmonary edema. Treatment for high-output congestive heart failure focuses on the primary pathology, which is skin inflammation. However, aggressive treatment of the inflammation with glucocorticoids may result in rapid resorption of extravascular fluid into the intravascular space and occurrence or aggravation of pulmonary edema. Erythrodermic patients with no clinical heart failure are also at risk for developing pulmonary edema if they receive glucocorticoids and/or intravascular fluids. Most hospitalists and dermatologists are not familiar with fluid administration and ways to manage cardiovascular function and blood pressure in patients with skin inflammation. Objectives and methods: In this article, we discuss the pathophysiology of vascular and fluid changes in the context of diffuse skin inflammation and provide some basic guidelines that can be presented to hospitalists by dermatologists. Limitations: Most of the recommendations and guidelines in the article are based on basic science and on the personal experience of the authors and are not supported by controlled trials. Capsule summary Diffuse skin inflammation causes major changes in the cardiovascular system and in the perfusion of internal organs. We provide guidelines for management of fluid status and cardiovascular function in patients with diffuse skin inflammation. Dermatologists can provide hospitalists or primary care providers with these guidelines to help them with creating better treatment plans.

Influence of standard corneal cross-linking in keratoconus patients on macular profile.

PURPOSE: To determine the effect of corneal cross-linking (CXL) on retinal structure and function. METHODS: The current study was conducted on 42 eyes of 21 patients with keratoconus (KCN) who were candidates for CXL due to disease progression. The Optovue optical coherence tomography (OCT) (Optovue Inc., Fremont, USA) from macula and multifocal electroretinography (mERG) were performed on all patients prior to surgery and at 1- and 6- month follow-up. Structural and functional parameters of macula including retinal thickness in OCT, and amplitude and latency of electroretinogram were compared between eyes that underwent surgery and control fellow eyes during the study period. RESULTS: A statistically significant increase in central foveal, foveal, parafoveal, and perifoveal thickness was observed at 1-month follow-up. The changes were non-significant at 6 months. Although a statistically significant reduction in amplitude and increase in latency in both rings 2 and 3 were observed at 1 month in mERG, only amplitude changes in ring 2 remained significant at 6 months. CONCLUSION: Transient anatomical and functional alterations following CXL were observed in the current study.

T-Lymphoblastic Leukemia/Lymphoma With Annular Skin Rash and Epidermotropism.

Leukemia cutis is uncommon in patients with acute lymphoblastic leukemia. It typically presents with dermal papules or subcutaneous nodules, with no epidermal or upper papillary dermal involvement on histopathology. We present an unusual clinical presentation of leukemia cutis, with annular plaques and epidermotropism.

The efficacy of short-term clobetasol lotion in the treatment of scalp psoriasis.

BACKGROUND: Scalp psoriasis can have a considerable impact on patients' quality of life and is considered difficult to treat. Treatment failure may, however, be due to poor adherence, as application of topical treatments to hair bearing areas is difficult and time consuming and also poor communication between physician and patient. OBJECTIVE: To assess the efficacy of short-term treatment of scalp psoriasis with topical clobetasol lotion. MATERIALS AND METHODS: Twelve patients with mild to severe scalp psoriasis were recruited for this study. Patients applied clobetasol 0.05% lotion twice daily for seven days. They were followed up with phone calls three days after starting the treatment. Skin hydration, transepidermal water loss (TEWL) and skin erythema were assessed noninvasively at baseline and end of study. RESULTS: One week after treatment, median PSI score decreased significantly (p = .002). There was also a significant decrease in median TEWL (p = .012) and increase in skin hydration one week after treatment (p = .010). Eighty three percent of patients were satisfied with treatment result and felt convenient with applying clobetasol lotion. LIMITATIONS: Lack of a long-term follow-up. CONCLUSIONS: Psoriasis is a long-term disease, and improving adherence in the short time could improve patient's adherence to treatment in long time.

Internet-based versus Conventional Referral System for Retinopathy of Prematurity Screening in Iran.

PURPOSE: To compare the efficacy of an internet-based versus traditional referral system for retinopathy of prematurity (ROP) screening in Iran. METHODS: Two referral screening systems were compared in this prospective observational study. Group A (internet-based) comprised premature babies who were registered into an online system for screening. Their appointments were scheduled automatically based on standardized criteria. Group B (conventional) comprised premature babies whose referrals were based on oral or written recommendations. Babies were referred based on standard criteria (gestational age, GA, <37 weeks or birth weight < 3000 g). RESULTS: A total of 2115 neonates were screened between October 2011 and October 2012. From these 1896 met the inclusion criteria (group A n = 856, group B n = 1040). Time of first examination for neonates with GA≤27 weeks was 30.07± 2.72 weeks postmenstrual age in group A and 38.52± 7.03 weeks in group B (p = 0.049), and for neonates with GA>27 weeks was 4.86 ±1.77 and 8.16 ±4.93 weeks after birth in groups A and B, respectively (p < 0.001). All registered babies in group A attended their first screening exam. One case (0.1%) of advanced ROP developed in group A (in a patient with poor follow-up compliance), whereas advanced stages of ROP were seen in 26 cases (2.5%) in group B (p < 0.001). CONCLUSION: An internet-based registration system for ROP screening resulted in fewer cases of delayed first examination and resulted in fewer babies with advanced ROP.

Retinopathy of prematurity screening criteria in Iran: new screening guidelines.

OBJECTIVE: To test the applicability of existing retinopathy of prematurity (ROP) guidelines on Iranian patients and to develop novel ROP screening criteria in Iran. METHODS: Both eyes of 1932 infants born ≤37 weeks of gestation and/or weighting ≤3000 g were included in this prospective cohort study that was conducted across nine neonatal intensive care units and a tertiary eye hospital ROP clinic. The patients were examined for ROP and the need for treatment (type 1 ROP or worse). All the patients were screened 4 weeks after birth or at 31 weeks of postmenstrual age, whichever was later. The patients were followed until retinal vascularisation was completed or the patients reached 50 weeks of gestational age (GA) without prethreshold ROP. A receiver operating characteristic curve was used to determine the best screening criteria for ROP. Screening criteria from other countries were applied to our patient data to determine their ability to appropriately detect ROP. MAIN OUTCOME MEASURE: Patients with ROP requiring treatment. RESULTS: The mean GA±SD and birth weight (BW)±SD of the screened patients were 32±2.7 weeks and 1713±516 g, respectively. Using criteria of GA≤32 weeks or BW ≤2000 yielded sensitivity and specificity of 100% and 26.7%, respectively, for treatment requiring ROP regardless of clinical comorbidities. Using screening recommendations of American Academy of Pediatrics would miss 25.4% of ROP and 8.4%ROP requiring treatment in our cohort. CONCLUSIONS: Other countries screening recommendations would result in a significant amount of missed cases of treatment requiring ROP when applied to Iran. As a result, we have proposed new guidelines for premature babies in Iran.

How Frequency of Electrosurgical Current and Electrode Size Affect the Depth of Electrocoagulation.

BACKGROUND: Many factors affect the depth of electrocoagulation. OBJECTIVE: To evaluate the effect of current frequency and electrode size on the depth of electrocoagulation. METHODS AND MATERIALS: In this in vitro study, 4 cylindrical electrodes (2, 2.3, 3, and 4 mm) were used to apply 3 electrosurgical currents (0.4, 1.5, and 3 MHz) to bovine liver. Each electrode was placed at different points on the surface of the liver, and energy at various levels and frequencies was delivered to the tissue. Subsequently, cross-sections of the liver were analyzed. RESULTS: Coagulation started at the periphery of the electrode-tissue contact area. With higher energy levels, coagulation spreads to involve the remainder of the contact area. Neither the frequency nor the electrode size had any effect on this coagulation pattern. The frequency of the current also did not show any relation with depth of coagulation; however, there was a direct correlation between the size of the electrode and the depth of coagulation. CONCLUSION: Larger-tip electrodes provided deeper coagulation compared with finer-tip electrodes.

Better Axial Stiffness of a Bicortical Screw Construct Compared to a Cable Construct for Comminuted Vancouver B1 Proximal Femoral Fractures.

The aim of this study was to biomechanically evaluate the Locking attachment plate (LAP) construct in comparison to a Cable plate construct, for the fixation of periprosthetic femoral fractures after cemented total hip arthroplasty. Each construct incorporated a locking compression plate with bi-cortical locking screws for distal fixation. In the Cable construct, 2 cables and 2 uni-cortical locking screws were used for proximal fixation. In the LAP construct, the cables were replaced by a LAP with 4 bi-cortical locking screws. The LAP construct was significantly stiffer than the cable construct under axial load with a bone gap (P=0.01). The LAP construct offers better axial stiffness compared to the cable construct in the fixation of comminuted Vancouver B1 proximal femoral fractures.

The existence of cords in olecranon bursae.

BACKGROUND: The purpose of this study was to document the existence of transverse cords in olecranon bursae in patients undergoing excision of the bursa and to describe the unique clinical presentation of patients with these cords. METHODS: A retrospective study was performed on 24 patients who had surgery to excise an olecranon bursa between 2006 and 2011. The patient's history, preoperative radiographs, ultrasound images, intraoperative photographs, and findings on histologic analysis were reviewed in all cases. RESULTS: Nine olecranon bursae had cords (cord group) and 15 did not have cords (noncord group). All patients in the cord group were male manual laborers, and nearly all had olecranon enthesophytes (n = 8). Patients in the noncord group had associated medical conditions or an infection. A higher level of satisfaction was reported in the noncord group after surgical excision. CONCLUSION: This study documents the existence of transverse cords oriented at right angles to the long axis of the olecranon. Olecranon bursae with cords have a unique presentation and are found in male manual workers, are nearly always associated with an olecranon enthesophyte, and do not present with infections.

Onychomycosis treatment in the United States.

Onychomycosis is a common progressive infection of the nails that may result in remarkable morbidity. Although there are a variety of treatments available for fungal nail infections with different efficacy and safety profiles, there are limited reports on the ways in which physicians use these treatments or the frequency with which they prescribe them. In this retrospective study, major trends in the prescription and use of antifungal agents for treatment of onychomycosis in the United States were evaluated using data from the National Ambulatory Medical Care Survey. Results showed that current treatment and trends in use of drugs for onychomycosis in the United States are in accordance with recommendations in current guidelines.

Topical clobetasol in conjunction with topical tretinoin is effective in preventing scar formation after superficial partial-thickness burn ulcers of the skin: A retrospective study.

BACKGROUND: Deep erythema and inflammation after re-epithelialization of superficial wounds is a sign of scar formation. Corticosteroids may prevent scarring by suppression of inflammation and fibroblast activity. Tretinoin may increase the efficacy of corticosteroids in this setting. OBJECTIVE: To evaluate the efficacy of corticosteroids plus tretinoin for prevention of scars after superficial wounds. METHODS: In a retrospective study of patients with superficial partial thickness thermal skin burn, we compared the patients who received clobetasol plus tretinoin after re-epithelialization with patients who did not receive any medication. Clobetasol propionate 0.05% ointment was used twice daily with overnight occlusive dressing in conjunction with twice weekly topical tretinoin 0.05% cream. RESULTS: Among 43 patients who had light pink or no erythema after re-epithelialization and consequently did not receive clobetasol + tretinoin, no scar was developed. Among patients who had deep erythema after re-epithelialization, rate of scar formation was significantly higher in 14 patients who did not receive clobetasol + tretinoin than in 21 patients who received clobetasol + tretinoin (64% and 19%, respectively; p = 0.01). CONCLUSION: Clobetasol + tretinoin can significantly decrease the incidence of scar formation in patients with inflammation after re-epithelialization of superficial wounds.

Gulliver's sign: A recognizable transition from inflammatory to healing stages of pyoderma gangrenosum.

BACKGROUND: Pyoderma gangrenosum (PG) often necessitates long-term immunosuppressant therapy. Many patients may receive treatment for longer periods and higher doses than is clinically necessary because clinicians may have difficulty differentiating between active disease and an inactive residual ulcer that is often slow to heal. OBJECTIVE: Recognition of the correct point to begin tapering therapy can help reduce the risk of adverse effects associated with treatment. RESULTS: This article describes Gulliver's sign, a recognizable transition in PG patients which indicates that inflammation is under control. CONCLUSION: This sign can be used to guide the tapering of corticosteroids and other immunosuppressant therapies in the treatment of PG.

The use of endemic Iranian plant, Echium amoenum, against the ethyl methanesulfonate and the recovery of mutagenic effects.

In this study, potential genotoxic effects of ethyl methanesulfonate (EMS) that caused mutagenicity in a variety of organisms were tried to resolve by the methanol and chloroform extract of Echium amoenum (EAmet and EAchl) Fisch. & C.A. Mey. from the family of Boraginaceae, which is an endemic plant, and is used as an alternative treatment among public in Iran. Somatic mutation and recombination test with Drosophila wing was used to determine the genotoxic and antigenotoxic effects in our investigations. For this purpose, 3-day-old transheterozygous larvae of mwh/flr(3) genotype of Drosophila melanogaster were used in all our experiments. The larvae were fed chronically on the Drosophila instant medium (DIM) including 1 ppm EMS. However, in another application group, different concentrations (1, 2 and 4 ppm) of EAmet and EAchl were added to DIM including 1 ppm EMS (EMS + EAmet and EMS + EAchl). Then, for the matured individuals, wing preparates were prepared within the mediums that include control group that has only DIM, negative control group that contains dimethyl sulfoxide and application groups in different concentrations that contain EMS, EMS + EAmet and EMS + EAchl. Clone induction frequency for the normal wing phenotype of EMS application group was observed to be 2.00. In the EMS + EAmet application group, the value of 1 ppm EAmet is 1.49, value of 2 ppm EAmet is 1.08 and value of 4 ppm EAmet is 0.72; in the EMS + EAchl application group, the value of 1 ppm is EAchl 1.33, value of 2 ppm EAchl is 0.67 and value of 4 ppm EAchl is 0.56 were determined. This decrease observed between EMS and all application groups in terms of total induction frequency is statistically significant (p < 0.05). These results concluded that chloroform extracts were more effective than the methanol extracts of E. amoenum.

Comparing demographic characteristics and adverse event rates at two dermatologic surgery practices.

BACKGROUND: Patient demographics and operative techniques may contribute to adverse events after surgeries. OBJECTIVE: To identify differences in adverse event rates between different dermatologic surgery centers and potential contributing features affecting these rates. METHODS: Data regarding demographics, procedure type, and adverse events were collected at two dermatologic surgery centers. RESULTS: The most common adverse event at both sites was infection: 2.1% at site 1 versus 0.5% at site 2 (p < .001). Using multivariate logistic regression, procedure type (Mohs surgery), geographic location (being at site 1), older age, and anatomic location of surgery were associated with a higher risk of infection. CONCLUSION: Adverse event rate appears to correlate with patient demographics, procedure type, and setting of surgery more than use of prophylactic antibiotics. Identification of differences in adverse event rates and potential contributing variables at different practices may allow for identification of opportunities to prevent adverse events.