Hand rejuvenation. The state of the art.

Intrinsic aging and photoaging, two distinct biologic processes, contribute to making hands appear aged. Restoration to a more youthful appearance for aged-appearing hands often requires a multitherapeutic approach individualized to the patient's pathology. This article reviews the role and technique of microlipoinjection for the rejuvenation of aged-appearing hands.

Application of the tumescent technique to hand augmentation.

The harvesting of fat for autologous implantation into the hands via the tumescent technique is presented. The tumescent technique, which involves the administration of large volumes of dilute local anesthetic into the donor site, results in low serum concentrations of anesthetic and produces long-lasting anesthesia while providing vasoconstriction and a firmness of the subcutaneous compartment ideal for lipoextraction. The tumescent technique has proven to be an important advance in reduction liposuction surgery. We describe our experience with the tumescent technique as applied to microlipoinjection for hand augmentation of aged and sun-damaged skin.

Silent bowel perforation occurring during corticosteroid treatment for pemphigus vulgaris.

We present the case of a patient who experienced a silent colonic perforation while being treated for pemphigus vulgaris with prednisone and azathioprine. Dermatologists are experienced in the management of pemphigus vulgaris with prednisone. We report a well-recognized but rarely reported adverse effect of this standard therapy for pemphigus vulgaris.

Health technology assessment: problems and challenges.

From a national perspective, the central prerequisite of the proper application of medical technology is the timely determination of efficacy, cost, safety, and societal impact. This applies to both the introduction of the new methods and the retirement of older methods that may have outlived their usefulness. Within that framework, the rapid diffusion of innovative methods of great value must be balanced against the cost of premature enthusiasm for techniques with little or no incremental diagnostic or therapeutic gain. A nongovernmental Council on Health Care Technology Assessment of the Institute of Medicine-National Academy of Sciences was established by the Congress in 1986. The Council was charged to serve as an information clearing-house, a center to promote research and education, and a stimulus to establish better methods of assessment and more prompt identification of potentially important technologies. It represents virtually all of the constituencies concerned with adequate evaluation of new and existing methods. The Council confronts the critical problems of timing, bias, the quality of primary data collection, new methods of secondary data analysis, the nature of the "laboratory" in which technology assessment is best accomplished, the "exploitative" character of technology assessment research, appropriate diffusion, and ethnical issues. The appropriate use of technology in modern health care depends on the resolution of these issues.

CT diagnosis of adrenal abnormalities in patients with primary non-adrenal malignancies.

Fifty-seven patients with primary non-adrenal malignancy were found to have unsuspected adrenal abnormality on CT. In 33, comparison of histopathologic findings and/or the patients' hospital course or follow-up lead to the diagnosis of adrenal metastases (23), benign non-functioning adenomas (7), metastasis with hyperplasia (1), benign hyperplasia (1), and fatty infiltration (1). The analysis of CT findings indicated that: I) A heterogeneous adrenal mass showing contrast enhancement was always metastatic, II) Nonfunctioning adenomas were always 3 cm or smaller in diameter, III) Bilateral adrenal masses and growth of adrenal mass on follow-up CT or regression on treatment indicated metastases, and IV) metastatic disease could not be excluded purely on the basis of the size of the adrenal mass.

Excretory urography in current practice: evidence against overutilization.

Excretory urography could be performed less frequently if some combinations of genitourinary signs and symptoms were found to be predictive of either a specific disease or normality. To explore this possibility, the authors conducted a prospective study involving more than 3,000 patients at three institutions (a teaching hospital, a community hospital, and a health maintenance organization). Predictive algorithms were obtained by application of a polychotomous logistic regression model but did poorly at differentiating normal from abnormal patients or arriving at a specific diagnosis. Selection of patients on the basis of the logistic model would have required testing 90% of all patients in order to detect 95% of those with abnormal urograms. These results suggest that current clinical selection criteria for excretory urography are effective, and that present frequency of utilization is appropriate.

Collateral arterial formation. Lymph draining ischemic kidneys contains a neovascular stimulating agent of high molecular weight.

An agent has been identified in lymph from rat kidneys rendered ischemic by partial renal artery occlusion that induces a striking neovascular response in a hamster cheek-pouch assay system. The factor has a high molecular weight, cannot be identified in lymph from normal kidneys, and is associated with a marked increase in vascularity and in endothelial cell turnover in the cheek pouch employed for assay. This factor may play an important role in the production of the collateral arterial circulation found in the presence of renal artery stenosis and renal ischemia.

Differentiation of malignant from benign adrenal masses: predictive indices on computed tomography.

CT findings in 43 adrenal masses were analyzed to see which features correlated most significantly with malignancy. Size, contrast enhancement, and consistency emerged as important discriminators of malignant from benign adrenal masses. These three factors were further analyzed by logistic regression technique to examine the joint influence of computed tomographic (CT) features in prediction of malignancy. As a result of logistic regression analysis, a table of estimated probability of malignancy as a function of tumor size alone and another table of estimated probability as a joint function of size and contrast enhancement were developed. Given a similar patient sample and by using the data given, it would be possible to predict chances of malignancy in an adrenal mass if its CT features are known; for example, a 5-cm adrenal mass without enhancement has a 0.31 probability of malignancy; with enhancement, a 0.68 probability.

Cost reduction opportunities in radiology departments.

The recent institution of prospective methods of hospital reimbursement has created a strong incentive to reduce costs. Significant savings were achieved in the cardiovascular-interventional radiology section of our hospital by obtaining competitive bids, purchasing in bulk, purchasing certain comparable but less expensive supplies, reducing film use, and altering patterns of use of some supplies.