Fractional ablative CO2 laser and oral isotretinoin-A prospective randomized controlled split-face trial comparing concurrent versus delayed laser treatment for acne scars.

BACKGROUND: Therapeutic dogma has been to treat acne scars with ablative fractional laser no less than 6 months after isotretinoin (ITN) cessation. OBJECTIVE: To evaluate the safety and efficacy of fractional ablative CO2 laser (FACL) in patients treated concurrently with ITN. METHODS: We conducted a prospective split-face randomized control trial in patients treated with FACL concurrently with ITN versus patients treated with FACL 6 months post-ITN treatment. Patients received 3 monthly sessions of FACL with concurrent ITN treatment on half of the face; the other side of the face received the same FACL treatment regimen 6 months post-ITN cessation. Patients were followed for adverse effects up to 6 months post-FACL treatment. Final cosmesis was scored using the Quantitative Global Acne Scarring Grading System (GASGS) by three independent dermatologists. RESULTS: The GASGS of the concurrent ITN-FACL treated side of the face was significantly lower than the side treated with delayed laser therapy (4.7 ± 2.5 vs. 7.7 ± 2.9, respectively, p < 0.001). LIMITATIONS: The laser's settings were standardized, and not adjusted per patient skin type. CONCLUSION: Per our prospective trial, concurrent treatment of FACL -ITN is superior to delayed FACL treatment 6 months post-ITN cessation. Fractional ablative laser treatment is effective in improving acne scars, which persist despite isotretinoin therapy.

A review of combined treatments for melasma involving energy-based devices and proposed pathogenesis-oriented combinations.

BACKGROUND: Melasma is an acquired disorder of hyperpigmentation, affecting a million individuals worldwide. Energy-based devices (EBDs) employed to treat melasma include various types of lasers, intense pulsed light (IPL), and radiofrequency (RF). Recent studies have attempted to address recalcitrant and recurring melasma by combining energy-based devices with topical or oral medications. OBJECTIVE: This article reviews EBDs-based augmented treatment for melasma and suggests practical pathogenesis-oriented treatment regimens. Treatment algorithms are proposed to address various components of melasma. METHODS: A systematic PubMed search was conducted acquiring information from various studies on combination treatments of melasma involving EBDs. RESULTS: The 286 retrieved articles were filtered by title to contain at least one type of energy-based modality such as laser, IPL, or RF along with at least one other treatment method. Based on their subject matter, combinations were further categorized into the subheadings: laser plus medication, laser plus laser, and IPL- and RF-containing treatment methods. CONCLUSION: There are many energy-based combination treatments that have been explored for mitigation of melasma including laser therapy with medication, multi-laser therapies, IPL, RF, and microneedling devices. Melasma is an exceedingly difficult condition to treat, however, choosing the appropriate tailor-made treatment combination can improve the final outcome.

Energy-based devices for the treatment of Acne Scars: 2022 International consensus recommendations.

BACKGROUND AND OBJECTIVES: Acne scars are one of the most distressing and long-term consequences of acne vulgaris, with damaging effect on a person's physical, mental, and social well-being. Numerous treatment options are available including surgical and nonsurgical techniques, depending on the clinical presentation. Although considerable advances in the development of new treatment technologies and applications have been made in the last decade, international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the potential utility of energy-based devices (EBDs) for acne scarring, offer recommendations for safe and efficacious treatment, and provide consensus-based EBD treatment options based on varying presentations demonstrated in a series of real-life clinical photographs. STUDY DESIGN/MATERIALS AND METHODS: An international panel of 24 dermatologists and plastic surgeons from 12 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the treatment of acne scars. A two-step modified Delphi method took place between March 2020 and February 2021 consisting of two rounds of emailed questionnaires. The panel members approved the final manuscript via email correspondence. RESULTS: The manuscript includes a comprehensive discussion and panel recommendations regarding the following topics: 1. the role of EBD in mitigating and treating acne scars in a patient with active acne, 2. the use of various EBDs for the treatment of different acne scar types with special focus on commonly used laser platform such as vascular lasers, ablative fractional lasers (AFLs) and non-AFLs (NAFLs), 3. treatment combinations, and 4. acne scar treatments in skin of color. The last part comprised of 10 photos of real-life clinical cases with the panel recommendation treatment plan to achieve best aesthetic outcome. CONCLUSION: Panel members were unanimous in their view that EBDs have a role in the management of acne scars, with AFLs, NAFLs, vascular lasers, and RF devices preferentially selected by most of the panel experts. EBDs are considered a first-line treatment for a variety of acne scar types and patients without access to these treatments may not be receiving the best available care for optimal cosmetic results. Future high-quality research and updated international treatment guidelines and reimbursement schemes should reflect this status.

A stereoscopic optical system for objective quantification of the change in cumulative acne scar depth following various treatment interventions.

BACKGROUND: Current approaches for assessment of acne scars are subjective, including counting scar subtypes, subjective self-assessment, or scoring global acne scar severity. AIMS: We aimed to validate accuracy and present initial data of a new, simple, non-contact, high-resolution 3D stereoscopic optical imaging system in the setting of acne scarring. PATIENTS/METHODS: Ten patients treated for acne scars in the dermo-esthetic outpatient clinics in our institution from July to December 2019 were recruited from medical files and completed by telephone interview. Each patient was assessed by the 3D imaging system, the Qualitative Scarring Grading Score (QSGS), and the patient's questionnaire for Self-assessment of Clinical Acne-Related Scars (SCARS) before and 4 weeks after a single intervention. RESULTS: Scar depth measured by the imaging system correlated significantly with the actual depth of printed surface depressions and the 3D optical imaging assessments. The changes in SCARS and 3D optical imaging assessments correlated significantly, but there were no correlations between changes in QSGS and 3D optical assessment measures, or between the QSGS and SCARS results. CONCLUSION: The new stereoscopic optical system is a reliable and practical objective method for assessing the cumulative depth of atrophic acne scars and monitoring treatment response. It is more sensitive, accurate, and informative than subjective scales.

Treatment of periorbital wrinkles using thermo-mechanical fractional injury therapy versus fractional non-ablative 1565 nm laser: A comparative prospective, randomized, double-arm, controlled study.

BACKGROUND: Non-ablative fractional laser is an effective modality for the treatment of periorbital wrinkling, one of the earliest signs of skin aging. Thermo-mechanical fractional injury (TMFI) therapy (Tixel®, Novoxel®, Israel) is an innovative technology that is now being used for facial skin rejuvenation. Our study compares the clinical results, side effects, and downtime profile between TMFI treatment and non-ablative fractional 1565 nm laser (ResurFX®, Lumenis, Israel). METHODS: This was a prospective study of 68 patients (64 women, 4 men) with skin types I-VI in two medical centers (34 from Israel, 34 from the USA) that were randomized to receive either TMFI or NAFL treatment for periorbital wrinkling. Patients received 3-5 treatments, 3-5 weeks apart. Six months after the last treatment, the change in Fitzpatrick Wrinkling Classification System (FWCS) was calculated by three non-involved physicians and compared to pretreatment results. Side effects and downtime profiles were assessed in each group (including VAS pain assessment, time required to refrain from work and social activity, and time required for the resolution of redness, edema, and crusts.) RESULTS: A moderate improvement in periorbital wrinkling was demonstrated in both groups, with an average improvement of 1.6 ± 0.6 in FWCS in the TMFI group and an average improvement of 1.7 ± 0.8 in the NAFL group (p < 0.001). Postprocedural VAS score was 5.86 ± 2.3 in the NAFL group and 4.01 ± 2.6 in the Tixel® group. Approximately 80% of subjects returned to both work and social activities two days postprocedure. Crusts were reported by 52% of patients in the TMFI group, compared to 16% of patients in the NAFL group more than 48 hours postprocedure (p < 0.05). There were no statistically significant differences in the other parameters between the two groups. CONCLUSION: TMFI is an effective and safe modality for the treatment of periorbital wrinkling, with comparable results to the 1565 nm NAFL.

Painting CROSS TCA technique: Modification of the CROSS method for the treatment of atrophic acne scars-Case series.

BACKGROUND: The Chemical Reconstruction of Skin Scars (CROSS) technique was first described in 2002 and has since demonstrated safety and efficacy in multiple studies. We describe the treatment of six patients with a modified version of the CROSS method-the Painting CROSS trichloroacetic acid (TCA) technique. This technique has the advantage of offering even higher tissue selectivity and better control of the scar edges, enhancing both safety and efficacy. METHODS: We retrospectively evaluated 31 scars of six patients who underwent a single treatment by the Painting CROSS TCA method. A 0.3 ml insulin syringe with a 30-gauge needle was filled with 0.05 ml of 85% TCA solution and then applied to the scar base with slight pressure until frosting was achieved. Patients were evaluated before and 3 months after treatment for scar volume deficit by a high-resolution three-dimensional imaging system. RESULTS: The average volume of the 31 scars assessed in our study was 2.71 mm3 before treatment and 1.96 mm3 after treatment. There was a 26.3% average decrease in the volume of the scars after one treatment. Transient mild hyperpigmentation was noted in two patients after the treatment. CONCLUSION: Painting CROSS TCA technique has demonstrated efficacy in the treatment of acne scars after a single treatment.

The pathogenesis of melasma and implications for treatment.

BACKGROUND: Melasma is a complex and poorly understood disorder, with high rates of treatment failure and recurrences. OBJECTIVES: We aimed to review the current knowledge of the pathogenesis of melasma and apply this knowledge to clinical implications on relevant therapeutic interventions. METHODS: A systematic PubMed search was performed using the search term "((melasma[Text Word]) OR facial melanosis[Text Word]) AND (pathogenesis OR causality[MeSH Terms])" for articles published between 1990 and 2020. Included articles were then evaluated by two authors and assessed for relevant pathomechanistic pathways, after which they were divided into groups with minimal overlap. We then reviewed current treatment modalities for melasma and divided them according to the involved pathomechanistic pathway. RESULTS: A total of 309 search results were retrieved among which 76 relevant articles were identified and reviewed. Five main pathomechanisms observed in melasma were identified: (1) melanocyte inappropriate activation; (2) aggregation of melanin and melanosomes in dermis and epidermis; (3a) increased mast cell count and (3b) solar elastosis; (4) altered basement membrane; and (5) increased vascularization. Treatment modalities were then divided based on these five pathways and detailed in 6 relevant tables. CONCLUSION: The pathophysiology of melasma is multifactorial, resulting in treatment resistance and high recurrence rates. This wide variety of pathomechanisms should ideally be addressed separately in the treatment regimen in order to maximize results.

Thermomechanical Ablation-Assisted Photodynamic Therapy for the Treatment of Acne Vulgaris. A Retrospective Chart Review of 30 Patients.

BACKGROUND AND OBJECTIVES: Acne vulgaris, a chronic inflammatory disease, affects more than 90% of teenagers. The first-line treatments for acne vulgaris are topical and oral medications, mainly antibiotics and retinoids. However, antibiotic resistance of Propionibacterium acnes, contraindications, partial response, significant adverse effects, or recurrence creates demand for novel treatment options in acne. Aminolevulinic acid (ALA) photodynamic therapy (PDT) is a well-established modality in the treatment of acne. Nevertheless, PDT has limitations: it may not be effective for every patient; several treatments are usually required to achieve sufficient outcome; incubation time is 1-3 hours; treatment pain and post-treatment downtime may be difficult for some patients to endure; and adverse effects may occur. This retrospective chart review was conducted to evaluate the efficacy and safety of PDT, assisted by a thermomechanical ablation (TMA) fractional injury device in the treatment of patients with moderate to severe acne. STUDY DESIGN/MATERIALS AND METHODS: We conducted a retrospective chart review of 30 acne patients treated with TMA immediately before 5% ALA application with an incubation time of 1 hour and exposure to 60 J/cm2 red light (630 nm). Patients received up to three monthly treatments and were followed for 16 weeks. Two independent investigators evaluated the subject outcomes according to high definition photographs taken at baseline, before each treatment and at follow-up visits. Three acne grading methods were used: Acne Grading Scoring System (AGSS), the Leeds revised acne grading system, and the general response to the treatment score. Patients also provided self-assessments of improvement using the patient global impression of change (PGIC). RESULTS: Compared with baseline, the AGSS has showed a statistically significant reduction of 26.7% and 23.7%, respectively, at weeks 8 and 16 after final treatment. The Leeds score showed 65.2% and 60.6% improvement at the respective visits. The overall response rate was graded 3.3 ± 0.5 out of 4. PGIC score given by the patients was 5.5 out of 7, reflecting high satisfaction. CONCLUSION: TMA used immediately prior to ALA application may enhance the effectiveness of PDT in the treatment of acne with minimal side effects, reduced downtime, and fewer sessions. The exact mechanism of TMA-assisted PDT is still to be understood. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Evaluation of subject response following treatment for pigmentation or wrinkles using a diode laser.

BACKGROUND: Pulsed diode array laser systems are utilized extensively for various aesthetic indications such as removal of unwanted hair, treatment of vascular and pigmented lesions, and wrinkle reduction. OBJECTIVE: The purpose of this study was to report and assess the experience of using a diode laser system delivering pulsed infrared laser light at the near-infrared (NIR) spectrum at wavelengths of 805 and 1060 nm. METHODS: The study was a retrospective analysis of treatment outcomes in adult subjects treated at the clinic between January 2017 and April 2018 for wrinkles and pigmentation with a noninvasive aesthetic diode laser system. Subjects were treated at nominal wavelengths of 805 nm for pigmentation and 1060 nm for wrinkles reduction. Improvement in pigmentation and wrinkles, adverse events, and patient tolerability to treatment and satisfaction were evaluated. RESULTS: Of 44 subjects with Fitzpatrick skin types II-IV, eight were treated for pigmentation and 36 for wrinkles. For both treatments, subjects reported tolerable pain levels. All immediate responses resolved within 48 hours post-treatment. Evaluation of treatment outcomes by two blinded evaluators demonstrated significant pigmentation clearance mean of 2.50 ± 0.15, (P < .05) in subjects treated for pigmentation, as well as significant improvement mean of 0.46 ± 0.12 (P = .005) in wrinkles in 13 subjects (41%) whose "before" and "after treatment" photographs were correctly identified by both blinded evaluators. Subjects were satisfied with the treatments. CONCLUSIONS: Use of the Diode laser effectively resulted in improvement in pigmentation and wrinkles, while maintaining a high safety profile with limited downtime.

Early intervention with pulse dye and CO2 ablative fractional lasers to improve cutaneous scarring post-lumpectomy: a randomized controlled trial on the impact of intervention on final cosmesis.

Light-based modalities appear to be effective for ameliorating surgical scar appearance; however, protocols for achieving such outcomes have yet to be established. We studied the safety and efficacy of a combination of pulsed dye laser (PDL) and fractional ablative CO2 laser (FACL) for the attenuation of post-lumpectomy scarring. We conducted a prospective, evaluator-blinded, comparative split-scar study in post-lumpectomy patients. One-half of the scar was treated with three sessions of 595-nm PDL and FACL at 1-month intervals, starting within 6 weeks after suture removal. The entire scar was also treated with standard moisturizers and silicone gels. Six months after the last treatment, the two halves of the scar were assessed by three uninvolved physicians who used the Observer Scar Assessment Scale as well as by the patients who used the Patient and Observer Scar Assessment Scale. Eighteen female patients (mean age, 51.3 years) with a mean scar length of 7.8 cm completed the treatment and follow-up. Six months after the last treatment, both the physician evaluators and the patients noted significant improvements for all assessed scar parameters in the laser-treated scar area compared with the untreated scar area. The treatment was well tolerated, and no remarkable adverse events were reported. All 18 participants were satisfied with the treated scar areas. A combination PDL and FACL protocol starting up to 6 weeks after suture removal is a safe and effective method for the attenuation of post-lumpectomy scar formation.

Novel Stereoscopic Optical System for Objectively Measuring Above-Surface Scar Volume-First-Time Quantification of Responses to Various Treatment Modalities.

BACKGROUND: Current approaches use subjective semiquantitative or cumbersome objective methodologies to assess physical characteristics of hypertrophic and keloid scars. OBJECTIVE: This pilot study aimed to evaluate the accuracy and feasibility of a new stereoscopic optical and high-resolution 3-dimensional imaging system, for objectively measuring changes in above-surface scar volume after various interventions. METHODS: Feasibility and accuracy were assessed by monitoring the above-surface scar volume of 5 scars in 2 patients for 5 successive months. Above-surface scar volume and Vancouver Scar Scale scores and the investigator and patient volume improvement assessment scores were assessed before and 12 weeks after last intervention. RESULTS: Scar volume measured by the imaging system correlated significantly with the gold standard (actual weight). The greatest volume reduction followed a combination of cryotherapy and intralesional triamcinolone acetonide and 5-fluorouracil injections in Patient 1 and a combination of pulse dye laser and intralesional triamcinolone acetonide injections in Patient 2. CONCLUSION: The new stereoscopic optical system is a valid, accurate, and practical objective method for assessing scar volume and for monitoring treatment response. It is more sensitive and accurate than semiquantitative objective scales. Further studies with a higher number of patients and scars are required to increase the measurement validity of the system.

9-cis-rich ß-carotene powder of the alga Dunaliella reduces the severity of chronic plaque psoriasis: a randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: Synthetic retinoids are one of the mainstay treatments of psoriasis. However, their use is occasionally limited by adverse effects, especially mucocutaneous, hepatic, and lipid profile toxicity. Thus, a search for retinoid metabolites that are both safe and active is essential. The alga Dunaliella bardawil is a natural source of the retinoid precursor 9-cis ß-carotene that has a good adverse effect profile. OBJECTIVE: To test the effect of the alga Dunaliella bardawil on psoriasis. METHODS: Thirty-four adult patients with mild, chronic, plaque-type psoriasis were included in this monocentric, prospective, randomized, double-blinded pilot study. Patients received either capsules of the alga D. bardawil or starch powder capsules, as the placebo, for 12 weeks. The response to treatment was evaluated by changes in Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) scores. Safety of the treatment was evaluated. RESULTS: At the end of 6 weeks, the reduction in the mean PASI score was significantly higher in the Dunaliella group than in the placebo group (61.3% vs 34%, respectively, p = 0.002). The DLQI change did not reach significance (8.5% and 5.9% in the Dunaliella and in the control group, respectively, p = 0.9). We observed no significant change in the liver function tests or in the lipid profile. CONCLUSIONS: 9-cis ß-carotene, in the form of D. bardawil, is an effective and safe treatment for patients with mild, chronic, plaque-type psoriasis. A larger study is warranted.

Clinical application of static fluorescence-based cytometry, Cellscan, in cutaneous adverse drug reaction.

The aim of the present study was to evaluate the effectiveness of Cellscan in identifying culprit drugs causing cutaneous adverse drug reaction. It was a prospective study with 3 months follow up conducted at the Departments of Dermatology, Internal Medicine and Dermatology Outpatient Clinic, Chaim Sheba Medical Center, Tel Hashomer, Israel. The study included 36 patients with cutaneous reaction suspected to be secondary to drugs, treated with a total number of 148 drugs. All patients and drugs were classified to three probability groups according to accepted clinical criteria. The effectiveness of the Cellscan test in identifying the culprit drug was addressed according to the clinical probability for cutaneous drug reaction, the drug class and the type of rash. Data analysis according to the clinical probability for cutaneous drug reaction revealed that patients in the moderate and high probability groups had a high test sensitivity of 77.7% and 83.3% with specificity of 71% and 63%, respectively, in identifying the culprit drug. Classifying the data according to drug classes, revealed that for the antibiotic and cardiovascular drug classes the sensitivity of the test was 100% and 92% with specificity of 83.3% and 55.5%, respectively, in identifying the culprit drug. Finally, the classification of patients according to the type of rash revealed a high evaluating accuracy for culprit drugs in maculopapular rashes with sensitivity and specificity of 90% and 60.4%, respectively. The results of this study imply that the Cellscan test is it a good practical tool for identifying the culprit drug in cutaneous adverse drug reaction.

Mycosis fungoides and CD30+ cutaneous T-cell lymphoma simulating pyoderma gangrenosum in a patient with ulcerative colitis.

BACKGROUND: Pyoderma gangrenosum is estimated to occur in 5% to 12% of ulcerative colitis patients. Primary CD30+ cutaneous large cell lymphoma is the second most common cutaneous lymphoma. It may coexists with mycosis fungoides. MAIN OBSERVATIONS: We report a 38-years-old female patient with 12 year history of ulcerative colitis, treated previously with 5-aminosalicylic acid and systemic corticosteroids. The disease has been in remission for the past 1.5 years, with no maintenance treatment. The patient then developed a rapidly progressing ulcerated lesion clinically simulating pyoderma gangrenosum. Physical examination revealed also a small number of hairless hypopigmented patches on the upper and lower limbs which she claimed to have appeared 4 years ago. Surprisingly a histological evaluation of the ulcer revealed a CD30+ primary cutaneous large cell lymphoma, while histology of hypopigmented lesions revealed mycosis fungoides, patch stage. T-cell receptor gene rearrangement from the two lesions didn't reveal the same T Cell clonalitiy and the patients lymphoma was stable. CONCLUSION: Our case presents the rare coexistence of primary mycosis fungoides and primary CD30+ cutaneous large cell lymphoma, rather than the CD30+ cutaneous large cell lymphoma developing from mycosis fungoides. This case also presents the development of a pyoderma gangrenosum-like lesion of CD30+ cutaneous large cell lymphoma in a patient with ulcerative colitis. An observation that emphasizes the need for a high index of suspicion in cases diagnosed as pyoderma gangrenosum based solely on clinical appearance.

The effectiveness of combined Chinese herbal medicine and acupuncture in the treatment of atopic dermatitis.

BACKGROUND: Patients with atopic dermatitis increasingly use complementary medicine. OBJECTIVE: The objective of this study was to assess the effectiveness of the combination of Chinese herbal medicine and acupuncture for the treatment of atopic dermatitis. METHODS: Twenty (20) patients between the ages of 13 and 48 who had mild-to-severe atopic dermatitis were given a combined treatment of acupuncture and Chinese herbal medicine and were followed prospectively. The patients received acupuncture treatment twice a week and the Chinese herbal formula 3 times daily for a total of 12 weeks. Assessments were performed before treatment, and at weeks 3, 6, 9, and 12 of treatment. The primary outcomes were defined as the changes in the Eczema Area and Severity Index (EASI), Dermatology Life Quality Index (DLQI), and patient assessment of itch measured on a visual analogue scale (VAS). RESULTS: After 12 weeks of treatment, an improvement in EASI was noted in 100% of patients, when compared with the baseline. The mean EASI fell from 4.99 to 1.81; the median percentage of decrease was 63.5%. Moreover, 78.8% of patients experienced a reduction in DLQI and VAS, as compared with the baseline. The mean DLQI decreased from 12.5 to 7.6 at the end of treatment, with 39.1% improvement. Mean VAS decreased from 6.8 to 3.7, with 44.7% improvement. No adverse effects were observed. CONCLUSIONS: The results of this study suggest that the combination of acupuncture and Chinese herbal medicine have a beneficial effect on patients with atopic dermatitis and may offer better results than Chinese herbal medicine alone.

A simplified fall-risk assessment tool for patients hospitalized in medical wards.

BACKGROUND: Falls are a common problem among hospitalized patients, having a significant impact on quality of life and resource utilization. OBJECTIVES: To develop and validate a fall-risk assessment tool for patients hospitalized in the department of medicine that will combine simplicity with adequate accuracy for routine use. METHODS: This observational cohort study was conducted on the medical wards of an urban tertiary teaching hospital, and included all patients who fell in the medical wards during a 1 year period (n = 140) compared to other hospitalized patients. RESULTS: Significant correlates of falls were previous falls, impairing medical conditions, impaired mobility, and altered mental state. In multivariate logistic regression analyses, only previous falls (odds ratio 3.8 with 95% confidence interval 2.65-5.45, P < 0.0001) and acute impairing medical conditions (OR 1.56, CI 1.06-2.29, P < 0.05) correlated independently with a higher risk for falls. Impaired mobility retained an OR of 1.46 (CI 0.95-2.24, P = 0.084). Accordingly, defining patients with either a history of previous falls or both acute impairing medical state and impaired mobility as fall-prone patients provided a sensitivity and specificity of 67% and 63%, respectively. In a subsequent prospective validation trial on 88 patients who fell during hospitalization and 436 controls, the sensitivity and specificity of this fall-risk grouping were 64% and 68% respectively. CONCLUSIONS: Our new simple and easy-to-use fall-risk assessment tool identified most of the fall-prone patients. These findings suggest that this tool may enable us to prevent two-thirds of falls on the medical ward by providing effective fall-prevention facilities to only one-third of the patients.

Metastatic angiosarcoma of the scalp causing Kasabach-Merritt syndrome.

We report a case of thrombocytopenia caused by Kasabach-Merritt syndrome (KMS) in a 69-year-old man with a metastatic angiosarcoma of the scalp. A review of the literature revealed that only 4 cases of KMS associated with angiosarcoma have been previously reported. All these cases occurred with a solitary large lesion. This is the first case of thrombocytopenia caused by KMS associated with small metastatic lesions of angiosarcoma that developed after the primary lesion has been completely removed.