Use of Amniotic Tissue-Derived Allografts Post-Mohs Micrographic Surgery: A Preliminary Study Assessing Wound Closure Rate.

INTRODUCTION: When closure is not feasible, Mohs micrographic surgical wounds typically are left to heal by secondary intention and require weeks to close. Amniotic tissue-derived allograft (ATDA) has proven successful in promoting wound closure in diabetic and refractory wounds, and it may be beneficial for patients who have undergone Mohs micrographic surgery. OBJECTIVE: The authors conducted a preliminary study to assess the efficacy of ATDA in speeding wound closure time and improving cosmetic outcomes in the specified patient population. MATERIALS AND METHODS: Patients received an injection of amniotic fluid, an overlay of amniotic membrane, or standard of care. Photographs of wounds taken at the time of treatment and at each subsequent visit were analyzed. RESULTS: The cosmetic outcome and time to wound closure appeared to be improved in patients treated with ATDA when compared with expected outcomes. Owing to small sample size, differences in initial defect size, and variety of body locations, the wound closure rate between treatment groups was not found to be significantly different with most comparisons. Statistical significance was seen, however, when normalized closure rates between membrane and control intervention were compared after outlier analysis (P = .0288). CONCLUSIONS: Data indicate that ATDA treatment may be beneficial and suggest that further investigation of the efficacy of ATDA to promote wound healing and improve cosmetic outcomes of post-Mohs surgical wounds is warranted. Future studies should be designed to match initial defect size and location between control and treatment groups.

Associations among parent and teacher ratings of systemizing, vocabulary and executive function in children with autism spectrum disorder.

Individuals with Autism Spectrum Disorder (ASD) show a heightened drive toward systemizing, which is the capability to analyze, or the drive to construct, a rule-based system. In addition, executive function deficits as well as diminished language capacity and vocabulary have been consistently demonstrated in individuals with ASD. The primary purpose of this study was to create a model to understand how these constructs interact in children with ASD. Forty-six children diagnosed with ASD along with their parents and teachers participated. All children completed standardized vocabulary testing. For each child, one parent and one teacher completed executive function and systemizing scales. For parents and teachers, systemizing was significantly associated with vocabulary. For parents, systematizing was significantly associated with all executive function subscales, however, for teachers, systemizing was only significantly associated with half of the executive function subscales. The mediation model indicated that the relationship between vocabulary and systemizing was fully mediated by executive function for parents but the model was not significant for teachers. This model demonstrates that systemizing, vocabulary and executive function should not be studied in isolation when attempting to understand the behaviors of children with ASD and can help us to better plan educational and therapeutic interventions.

Effects of acupuncture on chronic idiopathic pruritus: an uncontrolled pilot study evaluating inflammatory changes with treatment.

Background Conduct a pilot study addressing the efficacy of acupuncture in the treatment of chronic idiopathic pruritus to aid in the design of a larger clinical trial. Routine laboratory tests to assess systemic inflammation in addition to subjective patient surveys were performed provide documentation of efficacy of treatment. Methods Patients with chronic pruritus who did not respond to standard treatment were recruited to participate. After exclusion of systemic or known reversible causes, each patient received up to 10 treatments which were performed approximately one week apart. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured before and after a series of acupuncture treatments to evaluate levels of inflammation and pre- and post-treatment surveys were conducted to evaluate levels of perceived itch. Results Only one of the ten patients in this study possessed an elevation of ESR before treatment. This patient's ESR value returned to normal range after treatment and this participant reported subjective relief of her pruritus. Conclusions Future studies on the efficacy of acupuncture in the treatment of chronic idiopathic pruritus should focus on those patients with measurable levels of inflammation at the initiation of the study or utilize alternative and more comprehensive values to monitor disease response.

Cutaneous angioleiomyoma of the auricle: a painless variant of a painful tumour.

Cutaneous angioleiomyomas (ALMs) are uncommon benign tumours of the skin which derive from the smooth muscle layer of dermal blood vessels. They usually present as tender nodules in the fifth or sixth decade of life, predominantly in the legs of females. These tumours rarely present on the head and neck, especially the ear. Head and neck ALMs differ from their more common leg counterparts in that they are painless. Additionally, they do not manifest with a female predominance. Herein, a new case of a painless auricular ALM in a 63-year-old man is reported.

Associations Among Vocabulary, Executive Function Skills and Empathy in Individuals with Autism Spectrum Disorder.

BACKGROUND: Individuals with autism spectrum disorder (ASD) have been characterized as having deficits in social communication and empathy which present difficulties in the areas of social reciprocity, sharing of emotions and developing and maintaining relationships. This study explores the associations between vocabulary, executive function skills and empathy in individuals with ASD. METHOD: A survey study with a purposive sample was used. Twenty adolescents with ASD completed receptive and expressive vocabulary assessments while their parent and teacher completed executive function and empathy scales. RESULTS: Results indicated that higher vocabulary and executive function skills were associated with higher empathy. Nonparametric analyses also showed that executive function mediated the association between empathy and vocabulary. Differences between parent and teacher responses were also explored. CONCLUSIONS: The results suggest that targeting vocabulary and executive function skills prior to, or in conjunction with, social skills in educational and therapeutic settings may prove beneficial.

Safety Precautions and Operating Procedures in an (A)BSL-4 Laboratory: 2. General Practices.

Work in a biosafety level 4 (BSL-4) containment laboratory requires time and great attention to detail. The same work that is done in a BSL-2 laboratory with non-high-consequence pathogens will take significantly longer in a BSL-4 setting. This increased time requirement is due to a multitude of factors that are aimed at protecting the researcher from laboratory-acquired infections, the work environment from potential contamination and the local community from possible release of high-consequence pathogens. Inside the laboratory, movement is restricted due to air hoses attached to the mandatory full-body safety suits. In addition, disinfection of every item that is removed from Class II biosafety cabinets (BSCs) is required. Laboratory specialists must be trained in the practices of the BSL-4 laboratory and must show high proficiency in the skills they are performing. The focus of this article is to outline proper procedures and techniques to ensure laboratory biosafety and experimental accuracy using a standard viral plaque assay as an example procedure. In particular, proper techniques to work safely in a BSL-4 environment when performing an experiment will be visually emphasized. These techniques include: setting up a Class II BSC for experiments, proper cleaning of the Class II BSC when finished working, waste management and safe disposal of waste generated inside a BSL-4 laboratory, and the removal of inactivated samples from inside a BSL-4 laboratory to the BSL-2 laboratory.

Safety Precautions and Operating Procedures in an (A)BSL-4 Laboratory: 3. Aerobiology.

Aerosol or inhalational studies of high-consequence pathogens have recently been increasing in number due to the perceived threat of intentional aerosol releases or unexpected natural aerosol transmission. Specific laboratories designed to perform these experiments require tremendous engineering controls to provide a safe and secure working environment and constant systems maintenance to sustain functionality. Class III biosafety cabinets, also referred to as gloveboxes, are gas-tight enclosures with non-opening windows. These cabinets are maintained under negative pressure by double high-efficiency-particulate-air (HEPA)-filtered exhaust systems and are the ideal primary containment for housing aerosolization equipment. A well planned workflow between staff members within high containment from, for instance, an animal biosafety level-4 (ABSL-4) suit laboratory to the ABSL-4 cabinet laboratory is a crucial component for successful experimentation. For smooth study execution, establishing a communication network, moving equipment and subjects, and setting up and placing equipment, requires staff members to meticulously plan procedures prior to study initiation. Here, we provide an overview and a visual representation of how aerobiology research is conducted at the National Institutes of Health, National Institute of Allergy and Infectious Diseases Integrated Research Facility at Fort Detrick, Maryland, USA, within an ABSL-4 environment.

Safety Precautions and Operating Procedures in an (A)BSL-4 Laboratory: 4. Medical Imaging Procedures.

Medical imaging using animal models for human diseases has been utilized for decades; however, until recently, medical imaging of diseases induced by high-consequence pathogens has not been possible. In 2014, the National Institutes of Health, National Institute of Allergy and Infectious Diseases, Integrated Research Facility at Fort Detrick opened an Animal Biosafety Level 4 (ABSL-4) facility to assess the clinical course and pathology of infectious diseases in experimentally infected animals. Multiple imaging modalities including computed tomography (CT), magnetic resonance imaging, positron emission tomography, and single photon emission computed tomography are available to researchers for these evaluations. The focus of this article is to describe the workflow for safely obtaining a CT image of a live guinea pig in an ABSL-4 facility. These procedures include animal handling, anesthesia, and preparing and monitoring the animal until recovery from sedation. We will also discuss preparing the imaging equipment, performing quality checks, communication methods from "hot side" (containing pathogens) to "cold side," and moving the animal from the holding room to the imaging suite.

Safety Precautions and Operating Procedures in an (A)BSL-4 Laboratory: 1. Biosafety Level 4 Suit Laboratory Suite Entry and Exit Procedures.

Biosafety level 4 (BSL-4) suit laboratories are specifically designed to study high-consequence pathogens for which neither infection prophylaxes nor treatment options exist. The hallmarks of these laboratories are: custom-designed airtight doors, dedicated supply and exhaust airflow systems, a negative-pressure environment, and mandatory use of positive-pressure ("space") suits. The risk for laboratory specialists working with highly pathogenic agents is minimized through rigorous training and adherence to stringent safety protocols and standard operating procedures. Researchers perform the majority of their work in BSL-2 laboratories and switch to BSL-4 suit laboratories when work with a high-consequence pathogen is required. Collaborators and scientists considering BSL-4 projects should be aware of the challenges associated with BSL-4 research both in terms of experimental technical limitations in BSL-4 laboratory space and the increased duration of such experiments. Tasks such as entering and exiting the BSL-4 suit laboratories are considerably more complex and time-consuming compared to BSL-2 and BSL-3 laboratories. The focus of this particular article is to address basic biosafety concerns and describe the entrance and exit procedures for the BSL-4 laboratory at the NIH/NIAID Integrated Research Facility at Fort Detrick. Such procedures include checking external systems that support the BSL-4 laboratory, and inspecting and donning positive-pressure suits, entering the laboratory, moving through air pressure-resistant doors, and connecting to air-supply hoses. We will also discuss moving within and exiting the BSL-4 suit laboratories, including using the chemical shower and removing and storing positive-pressure suits.

Curcumin: A Contact Allergen.

BACKGROUND: Herbal medicines are used by thousands of patients all over the world. However, they can often cause adverse effects. Turmeric, made from the root of Curcuma, longa, is a yellow spice used throughout South Asia for its flavor as well as for its medicinal properties. Curcumin is the main ingredient in turmeric. It is known for downregulating the expression of various proinflammatory cytokines and has been studied for its antiinflammatory mechanism. However, it has also been reported to cause contact dermatitis. Kumkum, a turmeric-based powder applied by Hindu women on their foreheads, has also been found as an allergen. OBJECTIVE: The authors have reviewed the anti-inflammatory properties of curcumin and reports of contact dermatitis to understand the possible harmful effects of this commonly used spice, while also examining its beneficial role in dermatologic conditions. They aim to increase awareness regarding this common herb and its prevalent use not only in South Asia, but also in North America. METHODS: A thorough literature search of the PubMed database was conducted to identify studies that examined the antiinflammatory role of curcumin and its role in contact dermatitis. RESULTS: Eleven studies demonstrate that although curcumin does have antiinflammatory properties, it is an allergen. CONCLUSION: Curcumin has many valuable properties that can be exploited to treat dermatologic conditions. However, patients and dermatologists must be keen of possible allergic reactions. Further studies are needed to completely understand this widely used herb and its efficacy in dermatology.

Public Perceptions of Plastic Surgery: Analysis and Implications.

BACKGROUND: The general public may not fully appreciate the role that plastic surgeons play in patient care. The authors sought to identify public perceptions of plastic surgery in a major US urban setting. METHODS: A short, anonymous, survey was distributed to the public in all of the major boroughs of New York City. Respondents were asked to choose the surgeon they believed were experts in 12 specific clinical issues representative of required competencies by both the Plastic Surgery Residency Review Committee and the American Board of Plastic Surgery. RESULTS: A total of 1000 surveys were collected. Respondent demographics were similar by sex (53% women) and age (6% ages<21 years, 31% ages 21-24 years, 46% ages 25-40 years, 10% ages 41-54 years, and 8% ages ≥ 55 years). The majority also completed high school (96%). The percent of respondents who chose plastic surgeons as experts in the following procedures included rhinoplasty (61%), mandible fracture (12%), blepharoplasty (71%), cleft lip and palate surgery (46%), thumb replantation (32%), hand/finger fracture (18%), rhytidectomy (85%), breast reconstruction (87%), breast augmentation (96%), open leg wound (15%), open wound on the face (40%), and Botox (47%). Plastic surgeons were the most commonly selected experts in only 8 of these 12 domains (67%). These included rhinoplasty, blepharoplasty, rhytidectomy, Botox injections, breast augmentation, breast reconstruction, cleft lip and palate surgery, and treatment of open wound of the face. CONCLUSIONS: Unfortunately, many conditions at the core of plastic surgery remain outside the realm of plastic surgery in the opinion of the surveyed public.

Late-Start Days Increase Total Operative Time in Microvascular Breast Reconstruction.

BACKGROUND: Prolonged operative time has been associated with increased postoperative complications and higher costs. Many academic centers have a designated day for didactics that cause cases to start 1 hour later. The purpose of this study is to analyze the late-start effect of microvascular breast reconstructions on operative duration. METHODS: A retrospective review was performed on all patients who underwent abdomina-based free flap breast reconstruction from 2007 to 2011 and analyzed by those who had surgery on late-start versus normal-start days. Patient demographics, average operative time, postoperative complications, and individual surgeon effects were analyzed. A Student t-test was used to compare operative times with statistical significance set at p < 0.05. A multivariate regression analysis was performed to control for potential confounders. RESULTS: A total of 272 patients underwent 461 free flap breast reconstructions. Twenty-one cases were performed on late-start days and 251 cases were performed on normal-start days. Patient demographics and complications were not statistically different between the groups. The average operative time for all reconstructions was 434.3 minutes. The average operative times were significantly longer for late-start days, 517.6 versus 427.3 minutes (p = 0.002). This was true for both unilateral and bilateral reconstructions (432.8 vs. 350.9 minutes, p = 0.05; 551.5 vs. 461.2 minutes, p = 0.007). There were no differences in perioperative complications and multivariate regression showed no statistically significant relationship of confounders to duration of surgery. CONCLUSION: Starting cases 1 hour later can increase operative times. Although outcomes were not affected, we recommend avoiding lengthy procedures on late-start days.

Spherical photography and virtual tours for presenting crime scenes and forensic evidence in new zealand courtrooms.

The delivery of forensic science evidence in a clear and understandable manner is an important aspect of a forensic scientist's role during expert witness delivery in a courtroom trial. This article describes an Integrated Evidence Platform (IEP) system based on spherical photography which allows the audience to view the crime scene via a virtual tour and view the forensic scientist's evidence and results in context. Equipment and software programmes used in the creation of the IEP include a Nikon DSLR camera, a Seitz Roundshot VR Drive, PTGui Pro, and Tourweaver Professional Edition. The IEP enables a clear visualization of the crime scene, with embedded information such as photographs of items of interest, complex forensic evidence, the results of laboratory analyses, and scientific opinion evidence presented in context. The IEP has resulted in significant improvements to the pretrial disclosure of forensic results, enhanced the delivery of evidence in court, and improved the jury's understanding of the spatial relationship between results.

Clinicians performing cosmetic surgery in the community: a nationwide analysis of physician certification.

BACKGROUND: Practitioners who are not board-certified by the American Board of Plastic Surgery are practicing cosmetic surgery. The extent of this issue across the United States has yet to be examined in detail. METHODS: A systematic search using Google was performed to evaluate the qualifications of clinicians marketing themselves as plastic surgeons. For every U.S. state, the following searches were performed: [state] plastic surgery, [state] cosmetic surgery, and [state] aesthetic surgery. The first 50 Web sites returned for each search were visited and scrutinized using the American Society of Plastic Surgeons and American Board of Plastic Surgery Web sites. RESULTS: In total, 7500 Web sites were visited, yielding 2396 board-certified plastic surgeons (77.9 percent of all practitioners). There were 284 board-certified ear, nose, and throat surgeons, 61 (21.5 percent) of whom practice outside their scope; 106 board-certified general surgeons, 100 (94.3 percent) of whom practice outside their scope; 104 board-certified oral and maxillofacial surgery surgeons, 68 (65.4 percent) of whom practice outside their scope; 70 board-certified ophthalmologists/oculoplastic surgeons, 49 (70 percent) of whom practice outside their scope; and 74 board-certified dermatologists, 36 (48.6 percent) of whom practice outside their scope. There were also 16 internal medicine doctors, 13 obstetrics and gynecology physicians, six emergency medicine physicians, three pediatricians, two urologists, two anesthesiologists, and finally one phlebotomist; all of these practitioners practice outside their scope as defined by Accreditation Council for Graduate Medical Education core competencies. CONCLUSIONS: Many clinicians performing cosmetic surgery are not board-certified. This finding has important implications for patient safety.

Pediatric thenar flaps: a modified design, case series and review of the literature.

BACKGROUND: Fingertip injuries are extremely common in children, and severe trauma with pulp loss requires soft-tissue reconstruction to restore length, bulk, and sensibility. The thenar flap is a well-described technique but there are few reports of its use in pediatric patients. METHODS: Pediatric thenar flap reconstructions were retrospectively identified from October 2000 to October 2010 at a single institution. RESULTS: Sixteen pediatric patients (eleven male, five female) underwent thenar flap procedures. The average age was 10.8years (1.1-17.8years). The average defect size was 1.5cm×1.5cm (1cm(2)-2cm(2)). Division and inset occurred on average 16days later (12-24days). Average follow-up was 6.8months (4.1-9.6months). The average total active range of motion (TAM) in flexion was 248° (235°-260°) [normal maximum: 260°]. All patients had 85° metacarpophalangeal joint (MCPJ) range of motion (ROM) [normal maximum: 85°]. The average proximal interphalangeal joint (PIPJ) ROM was 103° (95°-110°) [normal maximum: 110°] in flexion, and an average 60° distal interphalangeal (DIPJ) ROM (55°-65°) [normal maximum: 65°] in flexion. Objective sensibility in the flap was ascertained as an average static two-point discrimination of 7mm (6mm-10mm) in 10 compliant patients and was grossly intact in all other patients. There were no complications. CONCLUSIONS: The thenar flap is a safe and effective option for pediatric fingertip amputation injuries requiring soft-tissue reconstruction.

Reconstruction of a functional gliding surface with extensor retinaculum in extensor tendon reconstruction in the digits.

BACKGROUND: Tendon gliding is key to optimal recovery of hand function after complex tendon injuries. Gliding is facilitated by a low-friction gliding surface that is normally provided by the periosteum of the underlying bone. However, significant injuries may damage the periosteum, which must be reconstructed to allow uninterrupted tendon excursion. The absence of the periosteum may compromise a tendon's ability to glide freely, thereby limiting the range of motion. METHODS: Six digits in 4 patients with complex, composite soft tissue defects involving tendon, periosteum, and skin of the hand underwent surgical repair. Each digit had disruption of the bony cortex underlying the tendon injury including periosteal loss. Through an incision on the dorsum of the ipsilateral wrist, an extensor retinaculum graft corresponding to the size of the periosteal defect was harvested. It was then sutured into place over the bare cortex to replace the lost periosteum. RESULTS: All the 6 digits in the 4 patients had complete return to function. Additionally, all patients had near normal strength in the repaired hand along with excellent tendon excursion in both flexion and extension. The average time of follow-up of this series of patients was 1.5 years. CONCLUSIONS: Extensor retinaculum grafting to replace lost periosteum is a technique that is easily used, uses locally available autogenous tissues, and produces excellent tendon function. Additionally, the histologic similarities between extensor retinaculum and periosteum add scientific merit to this novel approach. On the basis of our experience, we recommend the use of extensor retinaculum for periosteal reconstruction to provide an adequate gliding surface for a reconstructed tendon.