Association between the CD14 gene C-159T polymorphism and serum soluble CD14 with pulmonary tuberculosis.

BACKGROUND: Functional C-159T polymorphism in the promoter region of the CD14 lipopolysaccharide receptor has been reported to be associated with the development of tuberculosis (TB). OBJECTIVE: To assess the association of CD14 C-159T polymorphism and serum soluble CD14 (sCD14) levels with pulmonary tuberculosis (TB) in an Iranian population living in a TB-endemic area. DESIGN: A case-control study was performed prospectively on 120 newly diagnosed pulmonary TB patients and 131 healthy subjects. C-159T polymorphism was performed using amplification refractory mutation system polymerase chain reaction (ARMS-PCR). Concentrations of sCD14 were measured in serum samples using enzyme-linked immunosorbent assay. RESULTS: The genotype frequencies of C-159T polymorphism differed significantly between TB patients and controls (P = 0.006). The risk of TB was 2.3-fold greater in individuals with the T-allele (CT + TT) in comparison to those without (OR 2.3, 95%CI 1.2-4.3, P = 0.006). Mean total sCD14 was significantly increased in the serum of patients with newly diagnosed pulmonary TB (mean ± SD = 3177 ± 751 ng/ml) compared to healthy controls (mean ± SD = 2955 ± 424 ng/ml, P < 0.004). CONCLUSION: These data indicate that the C-159T polymorphism of the CD14 gene is associated with TB; serum sCD14 levels were higher in TB patients in a sample of the Iranian population.

A Parallel Computing Platform for Real-Time Haptic Interaction with Deformable Bodies.

Real-time simulation of haptic interaction with deformable objects is computationally demanding. In particular in finite-element (FE) based analysis of such interactions, a large system of equations must be solved at an update rate of 100-1,000 Hz for simulation fidelity and stability. A new hardware-based parallel implementation of a Preconditioned Conjugate Gradient (PCG) algorithm is proposed for solving the linear systems of equations arising from FE-based deformation models. Concurrent utilization of a large number of fixed-point computing units on a Field-Programmable Gate Array (FPGA) device yields a very fast solution to these equations. Quantization and overflow errors in the fixed-point implementation of the iterative solver are minimized through dynamic scaling and preconditioning. Numerical accuracy of the solution, the architecture design, and issues pertaining to the degree of parallelism and scalability of the architecture are discussed in detail. The implementation of the solver on an Altera EP3SE110 FPGA device has enabled real-time simulation of three-dimensional linear elastic deformation models with 1,500 nodes at an update rate of up to 2,500 Hz.

Face-lifting: an overview.

Numerous adaptations of face-lift techniques have been devised, and each surgical approach has its own risks and benefits, as well as proponents and detractors. All of the conventionally accepted techniques achieve removal of redundant skin. However, its the variations in approach to the deeper soft tissue structures that separate the many face-lifting procedures. A skin only face-lift was the earliest form of surgical rhytidectomy, but failed to achieve significant long-term benefit. Cosmetic surgeons of various backgrounds thus sought to achieve a more durable benefit from the surgery. While certain techniques have been classically ascribed to a particular surgeon, innovation does not occur in a vacuum and many surgeons are responsible for our current state of knowledge with regards to facial rhytidectomy surgery.

Dietetic guidelines: diet in secondary prevention of cardiovascular disease (first update, June 2003).

AIM: To update dietetic guidelines summarizing the systematic review evidence on dietary advice to prevent further events in people with existing cardiovascular disease (CVD) (secondary prevention). METHODS: The Cochrane Library, MEDLINE and EMBASE were comprehensively searched to November 2002 for systematic reviews on aspects of diet and heart health. Reviews were included if they searched systematically for randomised controlled trials relating to diet and secondary prevention of CVD. Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review. The quality and results of each review were discussed and summarized in a meeting of the whole group. RESULTS: Providing evidence-based dietary information (including increasing omega-3 fat intake) to all people who have had a myocardial infarction will save more lives than concentrating dietary advice on just those in need of weight loss or lipid lowering. The practice of prioritizing dietetic time in secondary prevention to those with raised lipids is out of date since the advent of statin therapy. However, effective dietary advice for those with angina, stroke, peripheral vascular disease or heart failure is less clear. CONCLUSION: There is good systematic review evidence that dietary advice to those with coronary heart disease can reduce mortality and morbidity as well as modify some risk factors. Dietary advice that does this most effectively should be prioritized.

Electrosurgical standing cutaneous cone modification.

BACKGROUND: Tissue redundancy manifesting as a standing cutaneous cone is a common surgical problem. OBJECTIVE: To describe the use of electrosurgery to modify standing cutaneous cones. METHODS: Electrical current is applied via an electrosurgical needle to deep dermis and subcutaneous fat. The superficial dermis and epidermis are left undisturbed. In properly selected standing cones, correction of the standing cone is achieved without scar lengthening. RESULTS: Use of the technique can provide standing cone correction without lengthening the surgical scar. There has been no increase in wound failure or infection with the described technique. CONCLUSION: Electrosurgical modification complements existing surgical techniques for standing cutaneous cone repair.

Topical tacrolimus in the treatment of bovine collagen hypersensitivity.

BACKGROUND: Soft tissue augmentation with bovine collagen is a common and safe aesthetic procedure. Despite adequate pretreatment testing, allergic reactions can develop. The medical literature provides little guidance to the clinician in the management of bovine collagen hypersensitivity. OBJECTIVE: We describe a case of bovine collagen allergy treated with 0.1% topical tacrolimus and corticosteroids. METHODS: Clinical evaluation and management of a patient with bovine collagen hypersensitivity. RESULTS: Our patient responded to combined therapy with oral corticosteroids and topical tacrolimus. CONCLUSION: Topical tacrolimus may be a useful first-line or adjuvant therapy in the management of bovine collagen allergic reactions. Further clinical experience with its use for bovine collagen hypersensitivity is required to determine its true efficacy in this condition.

Inverted pyramidal biopsy.

We describe a biopsy technique that is simple, rapid, and effective for numerous cutaneous lesions. The inverted pyramidal biopsy (IPB) creates an acute geometric tissue defect with an apex located in the dermis. A cosmetically pleasing result, while still providing adequate tissue to render a histologic description and diagnosis, is obtained. The technique can also be employed to remove a host of benign lesions, including dermatofibroma, fibrous papules, and chalazion, among others.

The quality of care in Barrett's esophagus: endoscopist and pathologist practices.

BACKGROUND: The diagnosis of Barrett's esophagus (BE) has important psychological and economic implications. Although accepted standards for endoscopic biopsy methods and pathological interpretation for BE exist, adherence to these standards as a measure of the quality of care in BE has not been evaluated. Our aim was to assess the quality of care in BE by evaluating the process of care and adherence to accepted standards of practice. METHODS: Explicit process-of-care criteria were developed using a systematic literature review and expert opinion in four domains of care: the quality of biopsy methods, the adequacy in identifying endoscopic landmarks, endoscopist-pathologist communication, and pathological interpretation and reporting. We reviewed all endoscopy and pathology reports of BE patients at two institutions from 1994-1997. An academic medical center (N = 237) with staff endoscopists and an academically affiliated community hospital (N = 100) with private-practice endoscopists were analyzed. RESULTS: Physicians showed the highest adherence to accepted standards of care in the "adequacy of identifying landmarks" and "endoscopist-pathologist communication" domains, with a > or =70% adherence rate in most criteria. Conversely, physicians demonstrated the poorest adherence with the "quality of biopsy methods" and "pathologist interpretation and reporting" domains, with adherence rates frequently <60%. Significantly, biopsies were taken in the presence of visible esophagitis 35% of the time. Performance on several of the quality indicators varied significantly by the practice setting. CONCLUSIONS: We have identified several opportunities for quality improvement efforts. In every domain, there is room for improvement, particularly in the quality of biopsy methods. As initiatives to screen the large population of gastroesophageal reflux disease patients for BE may be imminent, the time is now to define the critical process-of-care measures to minimize the risk of overdiagnosis and inadequate endoscopic surveillance.

The apical angle: a mathematical analysis of the ellipse.

BACKGROUND: The elliptical excision is a common surgical procedure. The dermatologic literature predominantly describes an excisional geometry with a 3:1 length:width ratio and an apical angle of 30 degrees. OBJECTIVE: To analyze the elliptical excision by applying mathematical principles and define the apical angle and its relationship to the length:width ratio. METHODS: We examined numerous examples of elliptical excisions as presented in the dermatologic literature. We analyzed the geometry of the excisions and defined it mathematically. RESULTS: The apical angle of a 3:1 elliptical excision is not 30 degrees. The true apical angle varies from 37 degrees to 74 degrees depending on excisional geometry. CONCLUSION: The commonly presented apical angle of 30 degrees is incorrect and does not reflect the true apical angle of elliptical excisions.

Series spiral advancement flap: an alternative to the ellipse.

BACKGROUND: Surgical excision of skin lesions is a common dermatologic procedure. OBJECTIVE: An alternative to the elliptical excision is described. METHODS: We present an excisional technique that creates a series of nonepidermal outwardly spiraling flaps. The surgical defect is closed with specially tunneled absorbable suture. RESULTS: There has been no increase in infectious complications or wound failures compared with standard ellipses. Proper patient and lesion selection aids in obtaining an acceptable outcome. CONCLUSION: The series spiral advancement flap has the potential to become a useful and common surgical technique.

Flap minimization via peripheral recruitment.

PURPOSE: To describe tissue-conserving modifications to traditional flap design such as the use of beveled incisions and the pattern of the incisions. These techniques should maintain flap viability and enhance cosmesis. METHODS: We describe the techniques of peripheral flap recruitment. RESULTS: Flaps conformed to reduced geometry, beveled incisions and bases, and tapered ends maximize vascularity. Peripheral tissues are recruited to fill primary defects; smaller flaps thus can be used to fill larger defects. Additionally, this flap design enhances cosmetic results and maintains a high probability for flap survival. CONCLUSION: The described novel flap design has many potential advantages over traditional designs. Correctly applied, these flap techniques spare tissue, decrease scarification, trauma and bleeding, and reduce the need for secondary procedures. Potential drawbacks of this flap design include temporary anatomic distortion especially over rounded structures such as the nose. Complications are minimal.

Cyclin D1 as an aid in the diagnosis of mantle cell lymphoma in skin biopsies: a case report.

Mantle cell lymphoma (MCL), an uncommon and aggressive form of non-Hodgkin lymphoma, typically involves lymph nodes. It usually only secondarily involves extranodal sites. We describe an unusual case of a MCL that presented and relapsed in the earlobes. Light microscopic findings were initially regarded as suggestive of small lymphocytic lymphoma, although subsequent analysis of fresh tissue by flow cytometry led to the diagnosis of MCL. Retrospective application of a broad panel of recently developed markers suitable for analysis of routinely processed tissue yielded results that also permitted a diagnosis of MCL. If these results had been available at the time of initial presentation, they would have obviated the need for rebiopsy. Greater awareness not only of the phenotypic criteria by which lymphomas are classified but of the lymphoma markers available for evaluation of routinely processed tissue should facilitate the accurate diagnosis of diseases like MCL and minimize the risk of misdiagnosis as an indolent disorder.

Electrosurgical modification of orbicularis oculi hypertrophy.

PURPOSE: To assess two electrosurgical approaches for the modification of orbicularis hypertrophy that may be used in conjunction with, or separate from, lower lid blepharoplasty. The hypothesis to be tested is that purely electrosurgical nonexcisional techniques may be used to modify orbicularis oculi muscle. METHODS: Electrosurgical techniques to treat orbicularis hypertrophy with an "open" and a "closed" technique are described. The open technique is performed in conjunction with transconjunctival blepharoplasty. The closed technique requires a 1-mm to 2-mm dermal incision, 2 minutes of surgical time per eyelid, and a specially insulated and formed electrosurgical needle. A review and case series are presented to illustrate and describe the techniques and results. RESULTS: Results for both techniques were rated by both patients and surgeons using the categories of poor, fair, good, or excellent. The open technique was performed in conjunction with transconjunctival blepharoplasty on 23 patients during 2 years with a minimum follow-up of 6 months. Results for the open technique were considered "excellent" by 14 patients and "good" by 9 patients. The operating surgeons evaluated the improvement as "excellent" in 4, "good" in 11, and "fair" in 8 patients. The closed technique was performed on eight patients. Results for patient satisfaction for the closed technique were considered "good" by 4, "excellent" by 2, "fair" by 1, and the final patient abstained from categorization. Operating surgeon evaluation of the closed technique revealed "excellent" outcomes in 3, "good" in 3, and "fair" for 2 patients. CONCLUSION: Electrosurgical techniques may be used to modify orbicularis hypertrophy. Drawbacks include a significant learning curve, potential cutaneous ulceration, and occasional temporary anatomic distortion as manifested by scleral show. Complications are minimal, and the technique was safe in all patients studied.

Mohs surgery and processing: novel optimizations and enhancements.

OBJECTIVE: Simple yet effective modifications to Mohs surgery and processing may enhance procedural efficiency, ensure proper tissue orientation and tracking, while greatly reducing "recuts." Using the methods described, Mohs specimens no longer need to be incised or excised with any bevel, thus conserving tissue and facilitating closure. METHODS: A streamlined Mohs surgical tray is convertible to a closure tray within seconds. The excised tissue specimen is oriented on a sterile paper square on a reusable sterilized aluminum palette where partial thickness circumferential and radial scalpel cross-hatching allows epidermal edges complete freedom to later adhere to a flattening glass. The sterile paper can be labeled with patient name, stage number, and chuck number; then the specimen is inked. Rapid chuck freezing in a specially positioned liquid nitrogen immersion is followed by OCT (embedding compound) application. Uniquely numbered and modified cryostat chucks eliminate the possibility of OCT-chuck disunion. Rapid liquid nitrogen immersion of a glass surface allows the inked, cross-hatched specimen's epidermal edges and base to lay perfectly flat once forced against the supercooled glass surface using a special polymer glove. Inversion of the specimen-containing glass onto a frozen and gel state OCT interface of the chuck completes the embedding. RESULTS/CONCLUSION: These reproducible approaches to Mohs surgery described herein utilize multiple modifications that enhance the speed, efficiency, and reproducibility of Mohs specimen embedding, specimen preparation, while maintaining accuracy of interpretation.

Self-limited adverse reaction to human-derived collagen injectable product.

BACKGROUND: Soft tissue augmentation is a common and safe cosmetic and reconstructive procedure. OBJECTIVE: We describe a temporary and self-limited adverse reaction to Dermalogen. METHODS: Clinical and histologic evaluation following an adverse reaction noted at a Dermalogen skin test site. RESULTS: Our patient was found to have a foreign body reaction to Dermalogen. CONCLUSION: Dermalogen, a form of acellular human collagen, may induce a foreign body reaction.

Alternative case definitions of ventilator-associated pneumonia identify different patients in a surgical intensive care unit.

Diagnostic criteria that define ventilator-associated pneumonia (VAP) remain controversial. The purpose of this study was to evaluate common definitions of VAP and determine their relationship to each other and clinical treatment. This study prospectively evaluated several diagnostic criteria that define VAP in a cohort of 255 consecutive SICU patients ventilated for < 48 h. Definitions evaluated include the CDC definitions, the Johanson definitions which do not rely on culture data, the Physician's Probable diagnosis which relies on positive quantitative cultures, and the antibiotic treatment group. Forty-four patients (17%) received antibiotic treatment for VAP. Depending on the definition evaluated, criteria were met for a diagnosis of VAP from as low as 4% of patients by the Johanson definition to as high as 48% of patients by the CDC definition. There was poor agreement among the definitions in their ability to select the same patient as having VAP. Besides duration of mechanical ventilation and tube feeding, which were risk factors that predicted meeting the criteria for all groups, risk factors predicting VAP varied among the definitions. This study demonstrates that in a surgical ICU, the candidate definitions of pneumonia evaluated show little agreement. The particular case definition chosen to diagnose VAP will determine the incidence rate of pneumonia, the time to onset of pneumonia, and the risk factors of the type of patient treated.

Personality disorders in elderly patients with dysthymic disorder.

The authors evaluated personality disorders in elderly patients with DSM-IV dysthymic disorder (DD) to identify prevalent personality disorders and their clinical correlates. Outpatients (>/=60 years; N=76) with DD were evaluated; most were male (65.8%) and had late age at onset (>50 years: 60.5%). Axis II disorders were present in 31.2% of patients, with obsessive-compulsive personality disorder (OCD; 17.1%) and avoidant personality disorder (11.8%) being the most common. Personality disorders were associated with an earlier age at onset of depressive illness, greater lifetime history of comorbid Axis I disorders, greater severity of depressive symptoms, and lower socioeconomic status. Personality disorders occurred in a minority of elderly patients with DD and mainly comprised the obsessive-compulsive and avoidant subtypes, similar to reports of personality disorders in elderly patients with major depression. In contrast, young adults with DD have been shown consistently to have personality disorders at high frequency. Together with the predominance of late onset and the lack of psychiatric comorbidity, the current findings on personality disorders reinforce our view that DD in elderly patients is typically a different disorder from DD in young adults.

A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities.

BACKGROUND: Controversy persists about the use of right unilateral (RUL) and bilateral (BL) electroconvulsive therapy (ECT). While RUL ECT results in less severe short-term and long-term cognitive effects, there is concern that it is less efficacious than BL ECT. METHODS: In a double-blind study, 80 depressed patients were randomized to RULECT, with electrical dosages 50%, 150%, or 500% above the seizure threshold, or BL ECT, with an electrical dosage 150% above the threshold. Depression severity and cognitive functioning were assessed before, during, immediately after, and 2 months after ECT. Compared with baseline, responders had at least a 60% reduction in symptom scores 1 week after ECT, and were monitored for relapse for 1 year. RESULTS: High-dosage RUL and BL ECT were equivalent in response rate (65%) and approximately twice as effective as low-dosage (35%) or moderate-dosage (30%) unilateral ECT. During the week after the randomized phase, BL ECT resulted in greater impairment than any dosage of unilateral ECT in several measures of anterograde and retrograde memory. Two months after ECT, retrograde amnestic deficits were greatest among patients treated with BL ECT. Thirty-three (53%) of the 62 patients who responded to ECT relapsed, without treatment group differences. The relapse rate was greater in patients who had not responded to adequate pharmacotherapy prior to ECT and who had more severe depressive symptoms after ECT. CONCLUSION: Right unilateral ECT at high dosage is as effective as a robust form of BL ECT, but produces less severe and persistent cognitive effects.

Electrosurgical suspension apparatus.

BACKGROUND: Dermatologic surgeons commonly employ electrosurgery. OBJECTIVE: We describe a novel, yet simple, electrosurgical suspension apparatus and variations that facilitate the performance of excision and repair, Mohs micrographic surgery, cosmetic surgery, and other forms of dermatologic surgery. METHODS: The described techniques result from more than a decade of use and refinements in electrosurgical suspension apparatuses. RESULTS: The use of an electrosurgical suspension device has eliminated electrosurgical needle stick injuries, facilitated surgery, and reduced the risk of surgical field contamination via the electrosurgical handpiece or wiring. CONCLUSION: The use of a suspended electrosurgical handpiece results in reduced surgical time, eliminates many of the inconveniences associated with the current use of electrosurgery, and facilitates the use of electrosurgery as a tool of the dermatologic surgeon.