Whole-Face Approach with Hyaluronic Acid Fillers.

The use of hyaluronic acid fillers in aesthetic medicine has changed over the years and the procedure became one of the most common in the world. Understanding the ageing process of the face and the anatomical interrelationships in the face have dramatically influenced the use of the hyaluronic acid fillers and the assessment of the patient. It was supported by a new technology of products and by the delivery of tools (eg, blunt cannulas), face imaging, and innovative injection techniques. The whole-face approach challenges the practitioner to look at the face as a whole, and the patient to trust and rely on the treatment plan. Over the years, we have understood, that the most important outcome of aesthetic procedures is what does the whole face look like not static but in motion, and how do people read emotions from it. Nowadays, the result changes "the face information" and makes aesthetic procedures more satisfactory. In this manuscript, we reviewed essentials of the current treatment approach including patient's consultations, product selection and injection techniques used in different parts of the face. One size fits none; thus, we provided a general overview of hyaluronic acid fillers used in different indications and presented several treatment approaches to each region of the face.

Arteriovenous graft for hemodialysis, graft venous anastomosis closure - current state of knowledge. Minireview.

UNLABELLED: Backround. The use of artificial vascular grafts (arteriovenous graft, AVG) is indicated in patients in hemodialysis programs if the subcutaneous venous bed is exhausted or unsuitable for arteriovenous fistula (AVF) creation. The native fistula should be the hemodialysis access of first choice: AVF has better results in terms of function and potential complications. However, the use of AVG is necessary in some patients. In these patients, extensive clinical examination, color duplex sonography and angiography should be performed prior to indication. The technique of graft implantation requires respect for geometric relations for the graft anastomoses to minimize the formation of intimal hyperplasia mainly on the venous anastomosis. The main complications of AVG are stenosis on the venous anastomosis (VAG), causing closure of graft and graft infection. The cumulative function of AVG is 59-90% in the first year and 50-82% in the second year. Arteriovenous graft stenosis leading to thrombosis is a major cause of complications in patients undergoing hemodialysis. The purpose of this review is to summarise current knowledge of the diagnostics and treatment of graft thrombosis and discuss the issue in combination with relevant publications via Pubmed database. CONCLUSION: The most frequent cause of failure of AVG for hemodialysis is stenosis and closure by VAG. AVG closure can be addressed surgically, endovascularly (amenable to thrombectomy by radiological or surgical means) and by hybrid performance.

Infected prosthetic dialysis arteriovenous grafts: a single dialysis center study.

BACKGROUND: The prosthetic arteriovenous grafts (AVG) being used increasingly to create hemodialysis access are prone to infections that pose potentially life-threatening infectious and bleeding complications, as well as loss of dialysis access. In this study, we identified the bacteriologic agents of infected AVGs by site swab, blood culture, and prosthesis cultures, and to evaluate the role of microbiological findings in the management of the infection. METHODS: We focused on 51 patients with 53 AVGs operated on in our clinic from January 2006 to December 2009. An infected AVG was identified by clinical, ultrasound, and microbiological findings. Sensitivity to antibiotics was determined for all bacterial strains. Isolates were identified by pulsed-field gel electrophoresis (PFGE) of bacterial DNA. In a few cases, positron emission tomography-computed tomography (PET-CT) examination was performed. RESULTS: Strains of Staphylococcus spp., especially S. aureus, were the most frequent cause of infected AVG. All S. aureus strains were sensitive to methicillin. With the exception of a single case, isolates obtained simultaneously from the skin site and the vascular prosthesis were identical genetically. CONCLUSIONS: Our results suggest that bacterial infectious agents detected in site swab, blood, or graft culture confirm a suspicion of AVG infection. A PET-CT examination can provide confirmation. The combination of microbiologic and radionuclide findings can improve the management of the AVG infection, but surgery remains essential.

Unused arteriovenous grafts as a source of chronic infection in haemodialysed patients with relevance to diagnosis of Fluorodeoxyglucose PET/CT examination.

INTRODUCTION: Clotted arteriovenous grafts (AVG) for haemodialysis which are not used (silent grafts) can serve as a potential source of chronic bacterial infection in patients on dialysis programs. In some cases, the local finding is unclear. The patient only suffers from repeated metastatic infection and the detection of AVG infection is difficult. Nuclear medicine methods have the potential to uncover AVG infection. In this study, we correlated the positron emission tomography (PET)/ computed tomography (CT) findings of the AVG examination with the microbiological findings from removed grafts. The aim was to evaluate the relevance of the Fluorodeoxyglucose (FDG) PET/CT method in detecting clotted graft infection. MATERIAL AND METHODS: A cohort of 13 patients with clotted grafts were followed-up. Four patients had overall symptoms of infection and 9 patients were asymptomatic. In all cases, the PET CT examination and microbiological examination of the removed graft were provided. RESULTS: Only one mismatch-negative PET CT finding and positive microbiological culture was recorded in the 13 followed-up patients. CONCLUSION: In patients with silent grafts and recurrent infection of equivocal aetiology, PET CT examination can contribute to the diagnosis of AVG infection and, subsequently, to prevent further infectious complications, if the AVG infection is treated appropriately and the graft is removed.

Surgical remodelling of haemodialysis fistula aneurysms.

INTRODUCTION: One complication of autogenous arteriovenous fistula (AVF) for haemodialysis is the formation of a venous aneurysm. CLINICAL PICTURE: The clinical picture is typically an expanding aneurysm leading to skin atrophy and ulceration with the risk of rupture and infection. Aneurysm also reduces the potential cannulation area. TREATMENT: The cases described here used a surgical 'remodelling' technique involving complete skeletonisation of the venous aneurysm, reduction of lumen diameter and retention of vein wall using a Hegar dilatator to remodel a new fistula. OUTCOME: Six patients were treated using this method and the arterior venous shunt (AVS) was used for haemodialysis the following day. No recurrent aneurysm developed. CONCLUSION: Remodelling of aneurysmal AVF is an effective and low-risk option for managing this kind of complication, allowing direct access for haemodialysis.

Skin cancer incidence in renal transplant recipients - a single center study.

AIMS: To provide the first single-center study of a Czech renal transplant program that compares skin cancer risk estimates to the general population. METHODS: We studied a total of 603 patients undergoing renal transplantation at the University Hospital Olomouc Transplant Center between January 1984 and December 2009. The mean time of follow-up was 5.5 years. Three patients were excluded for skin cancer diagnosis before transplant. The cohort was linked with the National Cancer Registry of the Czech Republic. For non-melanoma skin cancer (NMSC), the observed number of cancers were compared to the expected numbers of NMSC based on national cancer incidence rates stratified by age. The standartized incidence ratio (SIR) was calculated as observed-to-expected ratios. RESULTS: We found a total of 127 cases of skin cancers in 55 patients. 52/55 (94.5%) were patients with non-melanoma skin cancers, 2/55 (3.6%) patients had malignant melanoma, and we uncovered one case of merkel cell carcinoma of the skin (1.8%). There were no cases of Kaposi's sarcoma, cutaneous lymphoma or malignant fibrous histiocytoma. For NMSC, the overall SIR was 7.39 (95% confidence interval 5.52-9.70). Thus, skin cancer was the most common malignant condition, representing 64.1% of all malignant tumours detected in study population. CONCLUSION: We confirmed that skin cancer is a major complication in renal transplant recipients. Therefore it is important to increase the intensity of surveillence for these lesions in transplant patients.

Merkel cell carcinoma of the gluteal region with ipsilateral metastasis into the pancreatic graft of a patient after combined kidney-pancreas transplantation.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare tumour of the skin that predominantly affects elderly or immunocompromised patients. The malignant transformation of Merkel cells is currently considered to be related to an infection with Merkel cell polyomavirus. CASE REPORT: We present the case of a 62-year-old man who developed a Merkel cell polyomavirus-positive MCC in a non-UV-exposed part of the right gluteal region 8 years after combined kidney-pancreas transplantation. Following excision and radical re-excision of the tumour, no adjuvant radiotherapy was indicated because of the risk of adjacent pancreatic graft failure. Despite adjustment of the immunosuppressive therapy with conversion to sirolimus, the tumour generalised and metastasised into the pancreatic graft, leading to its failure. Subsequent chemotherapy did not affect the course of the disease, and the patient died 9 months after diagnosis. CONCLUSIONS: To our knowledge, we present the first case of MCC associated with metastatic involvement of the transplanted pancreas followed by its subsequent failure. Given the highly aggressive course of the disease in patients after organ transplantation, MCC therapy should be sufficiently aggressive from the time of diagnosis and should not be influenced by attempts to preserve graft function.

Infectious complications of arteriovenous ePTFE grafts for hemodialysis.

BACKGROUND: Insufficient venous vasculature disallows autologous arteriovenous fistula creation. In this case an arteriovenous conduit of expanded polytetrafluoroethylene (ePTFE) interponed between artery and vein is used for hemodialysis. Although arteriovenous graft infection is an infrequent complication, infected grafts cannot be used for hemodialysis and can cause infection, sepsis and bleeding. Treatment options remain limited but the general approach is to maintain functional angioaccess and to eradicate infection. AIM: To summarize current knowledge of the prevention and treatment of arteriovenous graft infection. METHODS: Literature review. CONCLUSIONS: ePTFE graft present an unreplaceable material used for angioaccess in patients with an insufficient venous vasculature. A number of risk factors causing graft infection is known. Since hemodialysis patients are a high-risk group, an effective strategies for graft infection prevention and early diagnosis should be determined. Among the most important risk factors belong surgical procedure, recurrent venipuncture and other infection disease. The prostheses should be removed when infected, especially in the presence of sepsis. In case of "localized infection", the prostheses can be removed partially only under the condition of careful patient selection and subsequent follow-up.

Post-transplant lymphoproliferative disorder.

BACKGROUND: Posttransplant lymphoproliferative disorder (PTLD) is increasingly recognized as a serious complication of solid organ transplantation in both children and adults. Factors associated with increased risk of PTLD include mismatch of recipient and donor EBV serologic status (seronegative recipient with seropositive donor), and intensive drug-induced immunosuppression. METHODS AND RESULTS: We searched MEDLINE for articles published since 1970 to January 2009. Search terms included posttransplant lymphoproliferative disorder, immunosuppression, posttransplant malignancy, treatment, antiviral agents, rituximab, interferon alpha, chemotherapy, radiation, surgery. Studies in English of adult and pediatric populations after solid organ transplantation were selected and analyzed. CONCLUSION: Screening of patients at risk and balancing the intensity of immunosuppression against the risk of allograft rejection could reduce the risk of developing PTLD. In patients who develop PTLD, the severity and extent of disease should be examined and an individualized treatment plan including immunosuppression reduction and other agents should accordingly be chosen.

Operating management of central venous hypertension complicating upper extremity dialysis access.

AIM: To evaluate the importance of surgical bypass between the terminal part of functional arteriovenous shunt (av) for hemodialysis on upper extremity and inner jugular vein in axillosubclavian venous segment obstruction associated with central venous hypertension. METHOD: Retrospective assessment of surgical bypass between central segments of av fistula and ipsilateral/contralateral inner jugular vein using ePTFE graft in 17 patients over a 20 year period (1987-2006). RESULTS: The surgical procedure was not associated with intra- or post-operative complications. Primary cumulative bypass and av fistula function persisted for 26 months on average. CONCLUSION: An accurate bypass to salvage the functional dialysis access associated with central venous hypertension requires careful decision based on clinical and radiological examination. The bypass procedure is beneficial where endovascular treatment is not indicated. Clinical and radiological bypass monitoring is crucial.