Medialized Trochanteric Starting Point and Focused Lateral Endosteal Beak Reaming to Optimize Success of Intramedullary Nailing in Atypical Femur Fractures: A Technical Trick and Case Series.

Optimal intramedullary treatment of atypical femur fractures associated with bisphosphonate use requires avoidance of postoperative malreduction, particularly varus. This can be difficult to achieve, given the fracture location, errors with nail entry point, endosteal beaking, and underlying patient osteology, all of which can contribute to postoperative varus and predispose the patient to treatment failure. We present a surgical technique and clinical series of 10 patients emphasizing a medialized trochanteric nail entry point and preferential lateral endosteal reaming to secure a biologically and biomechanically favorable reduction and fixation.

Intra-operative multi-dimensional fluoroscopy of guidepin placement prior to iliosacral screw fixation for posterior pelvic ring injuries and sacroiliac dislocation: an early case series.

PURPOSE: Traditional fluoroscopic techniques during percutaneous fixation of the posterior pelvic ring at times cannot adequately visualize errant or malpositioned iliosacral screws. Intra-operative fluoroscopic techniques have been advanced using multi-dimensional fluoroscopy to generate computed tomography-like images. This provides the surgeon not only the ability to assess iliosacral screw placement, but also the opportunity to assess reduction. We present a case series of four patients in which the Ziehm RFD multi-dimensional fluoroscopy was used to assess reduction and guidepin placement prior to definitive iliosacral screw fixation. METHODS: Four patients at our university level 1 trauma center with posterior pelvic ring disruptions were treated with percutaneous iliosacral screw fixation. Traditional fluoroscopic techniques were used during guidepin placement. Multi-dimensional fluoroscopy was performed using the Ziehm RFD 3D to assess guidepin placement and reduction prior to definitive iliosacral screw fixation. RESULTS: Our case series highlights two patients in which multi-dimensional fluoroscopy was utilized to ensure safe placement of iliosacral screws. In one of these two patients, a change was made after reviewing the imaging as a guidepin was found to be intruded into bilateral S2 neural tunnels. We also present two patient examples in which multidimensional fluoroscopy was used to assess reduction achieved by less invasive methods, precluding the need for direct visualization using more extensive open approaches. CONCLUSIONS: This retrospective case series demonstrates the direct impact that the Ziehm RFD 3D technology provides in surgical management of patients with complex posterior pelvic ring injuries.

Hyperglycemia following intralesional corticosteroid injection in a patient with type I diabetes mellitus.

CASE REPORT: A 36-year-old woman with well-controlled type 1 diabetes mellitus reported hyperglycemia (plasma glucose peaked at 21.3 mmol/L) after her first injection with intralesional triamcinolone acetonide for alopecia areata. CONCLUSION: Intralesional corticosteroids are used to maximize local effect while presumably minimizing systemic complications. This adverse effect is an important consideration when treating patients with insulin-dependent diabetes mellitus, and it would be reasonable to counsel patients of such a possibility.

Socioeconomic status influences care of patients with acne in Ontario, Canada.

BACKGROUND: Canada's universal health care system is designed to ensure equitable access to medical care based on need rather than socioeconomic status, although a number of studies indicate a preferential access and greater use of specialist services for those patients in higher socioeconomic groups. OBJECTIVES: The primary objective of this study was to determine whether socioeconomic status influences access to specialist care by a dermatologist for the management of acne in Ontario, Canada. A secondary objective was to determine whether the urban-rural dwelling status of patients affects access to specialty care. METHODS: We conducted a population-based cohort study using administrative health care databases covering more than 12 million residents of Ontario. Individuals age 12 to 27 years with a new diagnosis of acne by a general practitioner were identified as belonging to 1 of 5 socioeconomic groups based on median annual neighborhood household income. Patients were then observed for 2 years after the index visit to identify visits to a dermatologist. The main outcome measure was visitation to a dermatologist within 2 years of an initial diagnosis of acne. RESULTS: The study cohort consisted of 295,469 patients given a diagnosis of acne by their primary care physician of which 59,799 (20%) were subsequently referred to a dermatologist. Of those in the lowest income group of less than Can dollars 20,000, 17% were referred to a dermatologist, as compared with 24% in the highest income group of greater than Can dollars 80,000 (P value for trend < .001). Furthermore, patients living in an urban area had a 43% greater likelihood of being referred to a dermatologist (odds ratio 1.43, 95% confidence interval 1.39-1.48) as compared with patients in a rural location. LIMITATIONS: Limitations of our study include imputing socioeconomic status of patients on the basis of median income at the neighborhood level rather than on the basis of data on individual patients. Furthermore, our use of administrative databases did not allow us to characterize the severity of acne in our population cohort and whether that would affect referral patterns. CONCLUSION: Within Canada's universal health care system, those likely to be in lower socioeconomic groups are significantly less likely to visit a dermatologist for specialist consultation.

Evaluation of sun-protective practices of organ transplant recipients.

The incidence, morbidity and mortality of skin cancer are markedly increased in organ transplant recipients. Efforts aimed at reducing sun exposure through sun avoidance, sunscreens and sun-protective clothing are the most effective means to reduce the risk of skin cancer. We evaluated the sun-protective behaviors of 205 transplant recipients. Twenty-three percent of transplant patients continued to seek a tan. Thirty percent of patients did not use sunscreens, and of those patients who did, less than 5% were committed to using them daily. Thirty-seven percent of patients frequently wore hats and 39% of patients frequently wore additional clothing to block the sun. When data were stratified according to patient age, gender or skin phototype, we identified preferences for specific sun-protective methods. These data strongly suggest that many transplant recipients do not use adequate sun protection. Further study of strategies to encourage the use of sun protection among transplant patients is needed to reduce the incidence of skin cancer.

Treatment of acne vulgaris.

CONTEXT: Management of acne vulgaris by nondermatologists is increasing. Current understanding of the different presentations of acne allows for individualized treatments and improved outcomes. OBJECTIVE: To review the best evidence available for individualized treatment of acne. DATA SOURCES: Search of MEDLINE, EMBASE, and the Cochrane database to search for all English-language articles on acne treatment from 1966 to 2004. STUDY SELECTION: Well-designed randomized controlled trials, meta-analyses, and other systematic reviews are the focus of this article. DATA EXTRACTION: Acne literature is characterized by a lack of standardization with respect to outcome measures and methods used to grade disease severity. DATA SYNTHESIS: Main outcome measures of 29 randomized double-blind trials that were evaluated included reductions in inflammatory, noninflammatory, and total acne lesion counts. Topical retinoids reduce the number of comedones and inflammatory lesions in the range of 40% to 70%. These agents are the mainstay of therapy in patients with comedones only. Other agents, including topical antimicrobials, oral antibiotics, hormonal therapy (in women), and isotretinoin all yield high response rates. Patients with mild to moderate severity inflammatory acne with papules and pustules should be treated with topical antibiotics combined with retinoids. Oral antibiotics are first-line therapy in patients with moderate to severe inflammatory acne while oral isotretinoin is indicated for severe nodular acne, treatment failures, scarring, frequent relapses, or in cases of severe psychological distress. Long-term topical or oral antibiotic therapy should be avoided when feasible to minimize occurrence of bacterial resistance. Isotretinoin is a powerful teratogen mandating strict precautions for use among women of childbearing age. CONCLUSIONS: Acne responses to treatment vary considerably. Frequently more than 1 treatment modality is used concomitantly. Best results are seen when treatments are individualized on the basis of clinical presentation.

Specialty clinics for the dermatologic care of solid-organ transplant recipients.

BACKGROUND: Solid-organ transplant recipients constitute a complex patient population that experiences numerous and aggressive skin cancers. Proactive, comprehensive, ongoing, and effective dermatologic care of these patients is a necessity. OBJECTIVE: The objective of this study was to emphasize the need for organized dermatologic care for transplant recipients and to collect and present various proactive paradigms established in and designed for different practice settings to manage organ transplant recipients at high risk for skin cancer. METHODS: Information about practice setting, patient demographics, and the care model used was obtained through questionnaires sent to a selection of 12 physicians known to care for transplant recipients in various practice settings. RESULTS: All 12 physicians completed the questionnaire. The organized dermatologic care of transplant recipients occurs in three basic clinic settings: multidisciplinary transplant clinics, designated dermatology transplant subspecialty clinics, and integration of transplant recipient care within existing dermatology clinics. CONCLUSIONS: Various practice settings offer both advantages and disadvantages in providing preventive and therapeutic care of organ transplant recipients at risk for skin cancer. Regardless of the clinic design used, an organized and firmly established clinic model to allow proactive and ongoing care for these patients is important for education, prevention, and early intervention.

A systemic type I 5 alpha-reductase inhibitor is ineffective in the treatment of acne vulgaris.

Excessive sebum production is a central aspect of the pathophysiology of acne vulgaris. Sebaceous gland function is under androgen control and it is hypothesized that dihydrotestosterone is formed by the action of 5 alpha-reductase. Type I is the controlling isoenzyme. This study describes a 3-month, multicenter, randomized, placebo-controlled clinical trial with a potent, selective inhibitor of type I 5 alpha-reductase used alone and in combination with systemic minocycline. Inhibition of type I 5 alpha-reductase was not associated with clinical improvement of acne when used alone and did not enhance the clinical benefit of systemic minocycline. These results indicate the need for further work at the molecular level to better understand the action of androgens on sebaceous gland function.

Segmental neurofibromatosis follows blaschko's lines or dermatomes depending on the cell line affected: case report and literature review.

BACKGROUND: Segmental neurofibromatosis type 1 (NF-1) has the characteristic features of generalized NF-1 but is isolated to a particular segment of the body. Segmental NF-1 results from a postzygotic mutation during embryogenesis in the NF-1 gene on chromosome 17. The embryologic timing of the mutation and cell types affected predict the clinical phenotype. OBJECTIVE: We present a case of a 52-year-old woman with segmental neurofibromas isolated to the right cheek and neck. We review the recent literature on the genetic and cellular differences between the various clinical manifestations of segmental NF-1. METHODS: A MEDLINE search for cases of segmental neurofibromatosis was conducted. RESULTS: In patients with segmental NF-1 presenting as neurofibromas-only, the distribution follows a neural distribution in dermatomes because the genetic mutation appears to be limited to Schwann cells. In patients with pigmentary changes only, the NF-1 mutation has been shown to occur in fibroblasts and the distribution tends to follow the lines of Blaschko. CONCLUSION: Our patient's neurofibromas were secondary to a postzygotic mutation in the NF-1 gene of neural crest-derived cells. This mutation most likely occurred later in embryogenesis in cells that had already differentiated to Schwann cells and were committed to the dermatomal distribution of the right neck and cheek region (C2).

Recurrent adenoid cystic carcinoma of the scalp treated with mohs micrographic surgery.

Primary cutaneous adenoid cystic carcinoma is a rare skin neoplasm with a high potential for recurrence after local excision. We present a case of a 45-year-old white female with recurrent primary cutaneous adenoid cystic carcinoma of the scalp. The tumor was resected with Mohs surgery in two stages and defect repaired with split-thickness skin graft. There has been no recurrence of the tumor in the 12-month follow-up period.