The nanoscopic molecular pathway through human skin.

BACKGROUND: Knowledge regarding the barrier properties of human skin is important for understanding skin pathology, developing of transdermal drug delivery systems and computational skin absorption models; however, the molecular pathways through human skin remains to be fully investigated on a nanoscopic level. In particular the nanoscopic pathway of molecules passing the intercellular lipid bilayers separating the corneocytes in the stratum corneum (SC) is not fully elucidated. METHODS: Using stimulated emission depletion microscopy (STED) and Förster resonance energy transfer (FRET) the molecular pathways through the SC, the main barrier of the skin, are determined for lipophilic and water-soluble molecules at a nanoscopic resolution. RESULTS: Using STED and confocal microscopy, water-soluble dyes, were observed to be present in both the corneocytes and in the intercellular lipid matrix, whereas the lipophilic dyes were predominately in the intercellular lipid bilayers. FRET was observed in the SC between the lipophilic and water-soluble dyes, the existence of a minimum possible distance between acceptor and donor molecules of 4.0 ±â€¯0.1 nm was found. CONCLUSIONS: The results indicate that lipophilic molecules penetrate the stratum corneum via the intercellular lipids bilayers separating the corneocytes in the SC, while the more water-soluble molecules penetrate the stratum corneum via the transcellular route through the corneocytes and intercellular lipid bilayers via the polar head groups of lipid molecules in the bilayers. GENERAL SIGNIFICANCE: Knowledge of the nanoscopic molecular pathways through human skin will help understand the skin barrier function and will be of use for computational skin absorption models and transdermal drug delivery strategies.

Focus group parental opinions regarding treatment with topical corticosteroids on children with atopic dermatitis

Introduction and objectives: Atopic dermatitis is common among children of 0-5 years old. Treatment consists of emollients and topical corticosteroids. Due to corticophobia, however, adherence to topical corticosteroids is low. Our aim was to find factors that influence opinions about topical corticosteroids among parents of children with atopic dermatitis. Methods: A qualitative focus group study in secondary care with parents of children with atopic dermatitis. Questions concerned opinions, attitude, sources of information, and the use of topical corticosteroids. Results: The parents indicated that they lack knowledge about the working mechanism and side effects of topical corticosteroids. Dermatologists and paediatricians emphasise the beneficial effects, whereas other healthcare workers and lay people often express a negative attitude. Conclusions: This study gives a complete overview of factors influencing adherence. Treatment with topical corticosteroids can be improved by better informing parents about the working mechanisms, the use, and how to reduce the dose. Healthcare professionals need to be aware of the consequences of their negative attitude concerning topical corticosteroids

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Focus group parental opinions regarding treatment with topical corticosteroids on children with atopic dermatitis.

INTRODUCTION AND OBJECTIVES: Atopic dermatitis is common among children of 0-5 years old. Treatment consists of emollients and topical corticosteroids. Due to corticophobia, however, adherence to topical corticosteroids is low. Our aim was to find factors that influence opinions about topical corticosteroids among parents of children with atopic dermatitis. METHODS: A qualitative focus group study in secondary care with parents of children with atopic dermatitis. Questions concerned opinions, attitude, sources of information, and the use of topical corticosteroids. RESULTS: The parents indicated that they lack knowledge about the working mechanism and side effects of topical corticosteroids. Dermatologists and paediatricians emphasise the beneficial effects, whereas other healthcare workers and lay people often express a negative attitude. CONCLUSIONS: This study gives a complete overview of factors influencing adherence. Treatment with topical corticosteroids can be improved by better informing parents about the working mechanisms, the use, and how to reduce the dose. Healthcare professionals need to be aware of the consequences of their negative attitude concerning topical corticosteroids.

Outcomes reported in high-impact surgical journals.

BACKGROUND: With advances in operative technique and perioperative care, traditional endpoints such as morbidity and mortality provide an incomplete description of surgical outcomes. There is increasing emphasis on the need for patient-reported outcomes (PROs) to evaluate fully the effectiveness and quality of surgical interventions. The objective of this study was to identify the outcomes reported in clinical studies published in high-impact surgical journals and the frequency with which PROs are used. METHODS: Electronic versions of material published between 2008 and 2012 in the four highest-impact non-subspecialty surgical journals (Annals of Surgery, British Journal of Surgery (BJS), Journal of the American College of Surgeons (JACS), Journal of the American Medical Association (JAMA) Surgery) were hand-searched. Clinical studies of adult patients undergoing planned abdominal, thoracic or vascular surgery were included. Reported outcomes were classified into five categories using Wilson and Cleary's conceptual model. RESULTS: A total of 893 articles were assessed, of which 770 were included in the analysis. Some 91·6 per cent of studies reported biological and physiological outcomes, 36·0 per cent symptoms, 13·4 per cent direct indicators of functional status, 10·6 per cent general health perception and 14·8 per cent overall quality of life (QoL). The proportion of studies with at least one PRO was 38·7 per cent overall and 73·4 per cent in BJS (P < 0·001). The proportion of studies using a formal measure of health-related QoL ranged from 8·9 per cent (JAMA Surgery) to 33·8 per cent (BJS). CONCLUSION: The predominant reporting of clinical endpoints and the inconsistent use of PROs underscore the need for further research and education to enhance the applicability of these measures in specific surgical settings.

Systematic review of outcomes used to evaluate enhanced recovery after surgery.

BACKGROUND: Enhanced recovery pathways (ERPs) aim to improve patient recovery. However, validated outcome measures to evaluate this complex process are lacking. The objective of this review was to identify how recovery is measured in ERP studies and to provide recommendations for the design of future studies. METHODS: A systematic search of MEDLINE, Embase and Cochrane databases was conducted. Prospective studies evaluating ERPs compared with traditional care in abdominal surgery published between 2000 and 2013 were included. All reported outcomes were classified into categories: biological and physiological variables, symptom status, functional status, general health perceptions and quality of life (QoL). The phase of recovery measured was defined as baseline, intermediate (in hospital) and late (following discharge). RESULTS: A total of 38 studies were included based on the systematic review criteria. Biological or physiological variables other than postoperative complications were reported in 30 studies, and included return of gastrointestinal function (25 studies), pulmonary function (5) and physical strength (3). Patient-reported symptoms, including pain (16 studies) and fatigue (9), were reported less commonly. Reporting of functional status outcomes, including mobilization (16 studies) and ability to perform activities of daily living (4), was similarly uncommon. Health aspects of QoL were reported in only seven studies. Length of follow-up was generally short, with 24 studies reporting outcomes within 30 days or less. All studies documented in-hospital outcomes (intermediate phase), but only 17 reported postdischarge outcomes (late phase) other than complications or readmission. CONCLUSION: Patient-reported outcomes, particularly postdischarge functional status, were not commonly reported. Future studies of the effectiveness of ERPs should include validated, patient-reported outcomes to estimate better their impact on recovery, particularly after discharge from hospital.

Impact of a bladder scan protocol on discharge efficiency within a care pathway for ambulatory inguinal herniorraphy.

BACKGROUND: Postoperative urinary retention (POUR) is a common complication of ambulatory inguinal herniorraphy, with an incidence reaching 38%, and many surgeons require patients to void before discharge. This study aimed to assess whether the implementation of a bladder scan-based voiding protocol reduces the time until discharge after ambulatory inguinal herniorraphy without increasing the rate of POUR. METHODS: As part of a perioperative care pathway, a protocol was implemented to standardize decision making after elective inguinal hernia repair (February 2012). Patients were assessed with a bladder scan, and those with <600 mL of urine were discharged home, whereas those with more than 600 mL of urine had an in-and-out catheterization before discharge. The patients received written information about urinary symptoms and instructions to present to the emergency department if they were unable to void at home. An audit of scheduled outpatient inguinal hernia repairs between October 2011 and July 2012 was performed. Comparisons were made using the t test, Fisher's exact test, and Wilcoxon rank sum test where appropriate. Statistical significance was defined a priori as a p value lower than 0.05. RESULTS: During the study period, 124 patients underwent hernia repair: 60 before and 64 after implementation of the protocol. The findings showed no significant differences in patient characteristics, laparoscopic approach (35 vs. 33%; p = 0.80), proportion receiving general anesthesia (70 vs. 73%; p = 0.67), or amount of intravenous fluids given (793 vs. 663 mL; p = 0.07). The proportion of patients voiding before discharge was higher after protocol implementation (73 vs. 89%; p = 0.02). The protocol had no impact on median time to discharge (190 vs. 205 min; p = 0.60). Only one patient in each group presented to the emergency department with POUR (2%). CONCLUSION: After ambulatory inguinal herniorraphy, implementation of a bladder scan-based voiding protocol did not result in earlier discharge. The incidence of POUR was lower than reported in the literature.