Gender differences in PTSD severity and pain outcomes: baseline results from the LAMP trial.

Background: Post-traumatic stress disorder (PTSD) and chronic pain are highly prevalent comorbid conditions. Veterans dually burdened by PTSD and chronic pain experience more severe outcomes compared to either disorder alone. Few studies have enrolled enough women Veterans to test gender differences in pain outcomes [catastrophizing, intensity, interference] by the severity of PTSD. Aim: Examine gender differences in the association between PTSD symptoms and pain outcomes among Veterans enrolled in a chronic pain clinical trial. Methods: Participants were 421 men and 386 women Veterans with chronic pain who provided complete data on PTSD symptoms and pain outcomes. We used hierarchical linear regression models to examine gender differences in pain outcomes by PTSD symptoms. Results: Adjusted multivariable models indicated that PTSD symptoms were associated with higher levels of pain catastrophizing (0.57, 95% CI [0.51, 0.63]), pain intensity (0.30, 95% CI [0.24, 0.37]), and pain interference (0.46, 95% CI [0.39, 0.52]). No evidence suggesting differences in this association were found in either the crude or adjusted models (all interaction p-values<0.05). Conclusion: These findings may reflect the underlying mutual maintenance of these conditions whereby the sensation of pain could trigger PTSD symptoms, particularly if the trauma and pain are associated with the same event. Clinical implications and opportunities testing relevant treatments that may benefit both chronic pain and PTSD are discussed.

It's all about the perspective: Removing bias when co-managing patients with high-grade T1 bladder cancer and localized prostate cancer-A competing risks analysis.

The risk connotation of terminology in influencing decision-making should not be underestimated. For example, "superficial" T1HG bladder cancer has the same poor cancer-specific survival as that conferred by the "highest risk" prostate cancer (Gleason 10, T3b). Co-management of concomitant prostate cancer and non-muscle invasive bladder cancer requires a careful competing risk analysis by both the physician and patient. Herein, we detail how patients and physicians should be careful not to underestimate the risk attributed to "non-muscle invasive" bladder cancer.

Favre-Racouchot syndrome: a novel two-step treatment approach using the carbon dioxide laser.

BACKGROUND: Favre-Racouchot syndrome (FRS) is both disfiguring and difficult to treat. Available medical and surgical therapies are of variable efficacy. Most treatments do not achieve complete resolution and do not show maintenance of therapeutic response. OBJECTIVES: To assess the response to a novel two-step treatment using the CO2 laser in patients with FRS. METHODS: Seven patients with FRS were treated with the CO2 laser in resurfacing mode with manual expression of comedones under infiltrative local anaesthesia. The procedure was completed in one treatment session lasting 30 min and the wound was left to heal by secondary intention. A topical antibiotic was applied to treated areas, which were covered with a nonadherent dressing. All patients were assessed 3 months postoperatively by the operating laser surgeon and a visual assessment of clinical response to treatment in comparison with pretreatment photographs was made. Patient satisfaction was also recorded. RESULTS: All patients achieved complete resolution of FRS. The follow-up duration for our cohort ranged from 8 months to 3 years. Two patients required further treatment within a 2-3-year period from initial treatment. Disease relapse was noted over 1 year after the primary treatment; both these cases were smokers and repeat treatment with similar laser parameters maintained reproducible results. Our longest disease-free follow-up duration was 3 years postprimary treatment. The laser surgeons and patients reported high levels of therapeutic benefit and satisfaction with the results. CONCLUSIONS: This two-step treatment of FRS (CO2 laser resurfacing and manual pressure-induced expression of comedones) is an effective and durable treatment for FRS with an excellent cosmetic outcome. Long-term follow-up beyond 3 years is planned to determine whether later recurrence occurs with this technique.

Our perspective of the treatment of naevus of Ota with 1,064-, 755- and 532-nm wavelength lasers.

Naevus of Ota (NO) is a disfiguring pigmentary disorder affecting the face. Q-switched neodymium-doped yttrium aluminium garnet (QS Nd:YAG)-1,064 nm is a standard laser treatment because it causes highly selective destruction of melanin within the aberrant dermal melanocytes. However, not all lesions respond. This study aims to evaluate the efficacy/safety of QS Nd:YAG-1,064 nm and the shorter wavelength QS Alexandrite-755 nm and QS Nd:YAG-532 nm lasers in treating NO. Data were evaluated from 21 patients treated in our laser centre from 2004 to 2012. Lesional skin was irradiated with QS-532 nm/QS-755 nm/QS-1,064 nm, with settings titrated according to responses. All received initial test patches to direct initial wavelength choice, with subsequent treatments at 3-monthly intervals until clearance/lack of further response. Laser modality was switched following repeated test patches if there was no or no sustained improvement. Two thirds of patients had ≥ 90% improvement compared to baseline photographs. In 20% of patients, QS-1,064 nm was most efficacious with 97% mean improvement. The mean improvement was 80% for those in whom QS-755 nm was superior, and 90% for QS-532 nm. Median number of overall laser treatments was 8 (range 4-13). Number of treatments required varied significantly according to lesional colour and site: grey lesions and those on the forehead/temple were most resistant. We confirm successful treatment of NO with QS Nd:YAG-1,064 nm and the shorter wavelength QS-755 nm/QS-532 nm lasers without serious or irreversible side effects. We recommend judicious test patch analysis before treatment and a modality switch if complete clearance is not obtained.

A study of the efficacy of carbon dioxide and pigment-specific lasers in the treatment of medium-sized congenital melanocytic naevi.

BACKGROUND: Treatment of medium-sized congenital melanocytic naevi (CMN) can be challenging. OBJECTIVES: To present the results of treatment of 55 CMN with the carbon dioxide (CO(2) ) and pigment-specific lasers. METHOD: CO(2) and Q-switched lasers (frequency-doubled Nd:YAG, Nd:YAG and alexandrite) were used to treat 55 CMN. Patients were treated at 3-month intervals until maximum clearance. Clinical response at 3-6 months after final treatment was graded as poor (< 50%), good (50-75%) or excellent (> 75%). Outcomes were evaluated on case note review and questionnaire. RESULTS: Thirty-six of the 55 CMN were macular and 19 were mammillated. Twenty-seven CMN were present on the head and neck. For macular CMN, outcomes were better for truncal CMN. Scarring and pallor were seen in three lower limb macular CMN treated with a CO(2) laser. Mammillated CMN on the head and neck showed most improvement. Pigment-specific lasers were of no additional benefit. Repigmentation occurred in 6% of macular and 21% of mammillated CMN. Partial or complete regimentation of CMN was reported by 46% of patients. CONCLUSIONS: Compared with macular CMN, mammillated CMN show a marginally better response to laser treatment. CMN on the limbs respond poorly. Pigment-specific lasers do not lighten mammillated CMN. Adverse effects can occur with CO(2) laser treatment of macular CMN on lower limbs.

Carbon dioxide laser treatment of rhinophyma: a review of 124 patients.

BACKGROUND: Rhinophyma is a progressive, localized or generalized nasal deformity resulting from hypertrophy of sebaceous and connective tissue. The CO(2) laser has been used for treatment of rhinophyma, but the long-term efficacy of the treatment is unknown. OBJECTIVES: To review the outcome of 124 patients with rhinophyma treated with the CO(2) laser between 1996 and 2008 in our centre. PATIENTS AND METHODS: Exuberant sebaceous tissue was ablated using the Sharplan 40C CO(2) laser (Sharplan Lasers UK Ltd, London, U.K.) under local anaesthesia. The technique varied with the severity of rhinophyma; the laser was used in a continuous mode to debulk the larger rhinophymas, and in a resurfacing mode (Silk Touch scanner; Sharplan, 4-7-mm spot at 20-40 W) or continuous mode (10-20 W using a defocused 2-3-mm beam) to reshape the nasal contours. Outcomes were determined by case notes, clinical review and questionnaire. RESULTS: Laser treatment was completed in a single session in 115 of 124 patients. All patients were reviewed 3 months post-treatment. Results were classified as good to excellent in 118 and poor in six patients. All patients were sent a satisfaction questionnaire in 2008 and 52 patients replied. Patients reported high levels of satisfaction following treatment. The post-treatment response at 3-month review was maintained long term. The main complications were pain associated with injection of local anaesthetic, scarring and hypopigmentation (four patients) and open pores (two patients). CONCLUSIONS: The CO(2) laser is an effective and durable treatment for rhinophyma. Treatment carries a low risk of side-effects and is associated with high patient acceptability and satisfaction.

Pulsed-dye laser treatment of angioma serpiginosum.

Angioma serpiginosum (AS) is a rare, benign, vascular disorder comprising nonblanchable punctate red to purple lesions in a gyrate or serpiginous configuration. Tunable pulsed-dye laser (PDL) therapy has been successfully used in the treatment of AS. We report our results of treatment of 12 AS sites in eight patients who were treated with PDL. After an average of 3.75 treatments, complete resolution of AS was seen in five lesions, an excellent response in four and a good response in three. Self-limiting hyperpigmentation at the test sites was noted in two patients. This study provides further evidence of the efficacy of PDL for treatment of AS.

Mechanisms of endothelial differentiation in embryonic vasculogenesis.

The formation of new blood vessels in the adult organism not only contributes to the progression of diseases such as cancer and diabetic retinopathy but also can be promoted in therapeutic approaches to various ischemic pathologies. Because many of the signals important to blood vessel development during embryogenesis are recapitulated during adult blood vessel formation, much work has been performed to better-understand the molecular control of endothelial differentiation in the developing embryo. In this review, we describe the current understanding of where endothelial differentiation from pluripotent progenitor cells occurs during development, how this process is controlled at the molecular level, and what model systems can be used to investigate the earliest steps of blood vessel formation.

Break the cycle: the role of cell-cycle modulation in the prevention of vasculoproliferative diseases.

Atherosclerosis is a major health problem in the western world, and the effectiveness of interventional therapeutic modalities for symptomatic atherosclerotic lesions is limited by vessel restenosis. Proliferation and migration of smooth muscle cells (SMCs) play a central role in post-interventional restenosis. Accordingly, many therapeutic approaches attempt to inhibit SMC proliferation. As the cell cycle is a final common pathway in SMC proliferation, proteins of the cell cycle have emerged as logical targets for the treatment and prevention of restenotic lesions. In this review we discuss current approaches that target the cell cycle in smooth muscle cells, and also describe recent and ongoing clinical trials that involve cell-cycle manipulation in the treatment of vasculoproliferative diseases.

Management of a parturient with a history of local anesthetic allergy.

IMPLICATIONS: The management of parturients with a strong history of allergy to local anesthetics poses significant challenges to the obstetric anesthesiologist. We recommend that when such patients have a strong desire to receive labor analgesia with local anesthetics, they undergo provocative challenge testing with preservative-free bupivacaine performed in labor and delivery with preparations for emergent cesarean delivery after 24-wk gestation.

Audit of admissions to dermatology beds in Greater Manchester.

We present the results of a prospective questionnaire-based audit of admissions to dermatology beds. We examined the admission practices of clinicians and the outcome in terms of benefit to patients. The majority of patients (90%) were admitted because of the severity of their skin disease but other contributing factors included: inability to cope (40%); need for further investigation or observation (33%); coexisting medical factors (17%); poor social support; transport and psychological factors. Most (87%) patients benefited from admission and the dermatology life quality index improved by 42%. We demonstrate that inpatient treatment is effective and improves patients' quality of life.

Doppler ultrasound velocimetry for timing the second intrauterine transfusion in fetuses with anemia from red cell alloimmunization.

OBJECTIVE: Middle cerebral artery peak systolic velocity has been successfully used for timing the first cordocentesis in fetuses who are at risk for anemia because of maternal red cell alloimmunization. The effects on Doppler velocimetry after the intrauterine transfusion of adult blood to these fetuses are unknown. The objective of this study was to assess the applicability of Doppler methods for the prediction of severe anemia in fetuses who had undergone 1 previous intrauterine transfusion. STUDY DESIGN: Doppler examination of middle cerebral artery peak systolic velocity was performed before cordocentesis in 64 fetuses who had undergone 1 previous intrauterine transfusion. Timing of the second intrauterine transfusion was based on traditional criteria. Anemia was defined as mild (hemoglobin value between 0.84 and 0.65 multiples of the median), moderate (hemoglobin value <0.65-0.55 multiples of the median), and severe (hemoglobin value <0.55 multiples of the median). Receiver operator characteristic curves were created to select threshold values to identify the 3 degrees of anemia with a sensitivity of 100%. RESULTS: Gestational age at the Doppler study ranged from 19 to 36 weeks. Forty-six fetuses (72%) were not or mildly anemic; 7 fetuses (11%) were moderately anemic, and 11 fetuses (17%) were severely anemic. Middle cerebral artery peak systolic velocity for the prediction of severe, moderate, and mild anemia at a sensitivity of 100% showed false-positive rates of 6%, 37%, and 70%, respectively. CONCLUSION: In fetuses who have undergone 1 previous intrauterine transfusion because of maternal red cell alloimmunization, timing the second intrauterine transfusion can be determined noninvasively by Doppler ultrasonography on the basis of an increase in the peak velocity of systolic blood flow in the middle cerebral artery.

Transporting the incubator: effects upon a region of the adoption of guidelines for high-risk maternal transport.

OBJECTIVE: To inventory maternal transport practices and develop regional transport guidelines. STUDY DESIGN: A survey was administered to perinatal nursing directors of nine community hospitals in a rural region of Virginia. Items included personnel, training, equipment, vehicle, communication, and protocols. Following the survey, regional guidelines were developed using a collaborative process. Their use was promoted in the region. A post-intervention survey documented changes in transport practices. RESULTS: The pre-intervention survey showed wide variability in training and number of personnel and in availability of emergency equipment. Communication was via radio to a dispatcher. No hospital had standing orders or protocols for transport. Guidelines were developed, which included recommendations for personnel, equipment, vehicle, communication methods, and care protocols. Eight of nine hospitals endorsed the guidelines. A follow-up survey revealed practice changes for standing orders/protocols, communication, and equipment. CONCLUSION: Regionwide practice changes can be successfully implemented. Guidelines may be helpful for other regions using primarily one-way maternal transports.

Carcinoma cuniculatum of the foot assessed by magnetic resonance scanning.

We describe a case of carcinoma cuniculatum of the foot assessed by magnetic resonance scanning. The potential use of this imaging technique in the management of this condition is discussed.

Color Doppler ultrasonography of the superior mesenteric artery for prenatal ultrasonographic diagnosis of a left-sided congenital diaphragmatic hernia.

The incidence of congenital diaphragmatic hernia (CDH) has been estimated as 1 per 2000 to 1 per 4000 births. The etiology of the malformation is unknown, but it has been reported in association with maternal administration of medications such as thalidomide or antiepileptics before closure of the pleuroperitoneal canal at 9 to 10 weeks' gestation as well as having a familial inheritance pattern. Congenital diaphragmatic hernia is associated with other congenital anomalies in 25% to 57% of cases and with chromosomal abnormalities in 10% to 20% of cases. Posterolateral, anterolateral, and pars sternalis defects of closure of the pleuroperitoneal canal encompass the 3 types of CDH. The most frequent type is the left-sided posterolateral defect or Bochdalek's hernia, which accounts for 81% of cases.

Initial development of a system-wide maternal-fetal outcomes assessment program.

OBJECTIVE: This study was undertaken to develop a comprehensive risk-assessment approach capable of evaluating maternal and fetal outcomes. STUDY DESIGN: Data from 10,984 women and 11,066 infants delivered at 79 military treatment facilities in the United States from 1995 to 1997 were used to develop two individual but complementary risk-adjustment models for maternal and, separately, fetal outcomes. A range of maternal and delivery-related risk variables and clinically important outcomes were identified by expert opinion and selected and weighted with ordinal logistic regression analysis. Receiver operating characteristic curves for the maternal and fetal models were determined. Variation across the facilities in risk-adjusted performance was also evaluated. RESULTS: Risk factors and poor outcomes were rare for both mothers and infants, with 96.9% of infants and 97.7% of mothers having good or excellent outcomes (0.7% mortality and 0.01% mortality, respectively). Despite the low frequency of poor outcomes both models performed well, with receiver operating characteristic curves of 0.75 for maternal outcomes and 0.78 for infant outcomes. When the models were applied to the military treatment facilities, there were significant differences among facilities in risk-adjusted outcomes. Twenty-four of the facilities in the study (30%) had outcomes odds ratios that were significantly >1 or significantly <1 (P <.05). There did not appear to be any relationship between the performance of a military treatment facility for maternal outcome and that for infant outcome. CONCLUSION: Complementary risk models for maternal and infant outcomes were developed that had satisfactory discriminatory power across a variety of facilities within a large health system. With further development and refinement this approach holds promise of being able to detect variations in risk-adjusted performance that could be used to identify best practices. The results might also be used to help coordinate and improve the quality of care for the entire conception-to-delivery process.

Ethical theory and principles: do they have any relevance to problems arising in everyday practice?

This review of ethical theories with application to two difficult obstetric cases will allow the practicing obstetrician and gynecologist to use these theories to help resolve difficult ethical dilemmas. In the first case a pregnant human immunodeficiency virus-infected woman refuses to take triple preventive therapy, with potential fetal harm. In the second case a couple with a quintuplet multifetal pregnancy needs assistance to decide about selective termination to effect fetal reduction.