A diverse diapsid tooth assemblage from the Early Triassic (Driefontein locality, South Africa) records the recovery of diapsids following the end-Permian mass extinction.

Mass extinctions change the trajectory of evolution and restructure ecosystems. The largest mass extinction, the end-Permian, is a particularly interesting case due to the hypothesized delay in the recovery of global ecosystems, where total trophic level recovery is not thought to have occurred until 5-9 million years after the extinction event. Diapsids, especially archosauromorphs, play an important role in this recovery, filling niches left vacant by therapsids and anapsids. However, the nature of lineage and ecological diversification of diapsids is obscured by the limited number of continuous, well-dated stratigraphic sections at the Permian-Triassic boundary and continuing through the first half of the Triassic. The Karoo Basin of South Africa is one such record, and particularly the late Early Triassic (Olenekian) Driefontein locality fills this gap in the diapsid fossil record. We collected a total of 102 teeth of which 81 are identified as diapsids and the remaining 21 as identified as temnospondyls. From the sample, seven distinct tooth morphotypes of diapsids are recognized, six of which are new to the locality. We used a combination of linear measurements, 3D geomorphometrics, and nMDS ordination to compare these morphotypes and made inferences about their possible diets. Although the morphotypes are readily differentiated in nMDS, the overall morphological disparity is low, and we infer five morphotypes are faunivorous with the other two potentially omnivorous or piscivorous based on their morphological similarities with dentitions from extant diapsids, demonstrating an unsampled taxonomic and ecological diversity of diapsids in the Early Triassic based on teeth. Although ecological specialization at Driefontein may be low, it records a diversity of diapsid taxa, specifically of archosauromorph lineages.

First hominine remains from a ~1.0 million year old bone bed at Cornelia-Uitzoek, Free State Province, South Africa.

We report here on evidence of early Homo around 1.0 Ma (millions of years ago) in the central plains of southern Africa. The human material, a first upper molar, was discovered during the systematic excavation of a densely-packed bone bed in the basal part of the sedimentary sequence at the Cornelia-Uitzoek fossil vertebrate locality. We dated this sequence by palaeomagnetism and correlated the bone bed to the Jaramillo subchron, between 1.07 and 0.99 Ma. This makes the specimen the oldest southern African hominine remains outside the dolomitic karst landscapes of northern South Africa. Cornelia-Uitzoek is the type locality of the Cornelian Land Mammal Age. The fauna contains an archaic component, reflecting previous biogeographic links with East Africa, and a derived component, suggesting incipient southern endemism. The bone bed is considered to be the result of the bone collecting behaviour of a large predator, possibly spotted hyaenas. Acheulian artefacts are found in small numbers within the bone bed among the fossil vertebrates, reflecting the penecontemporaneous presence of people in the immediate vicinity of the occurrence. The hominine tooth was recovered from the central, deeper part of the bone bed. In size, it clusters with southern African early Homo and it is also morphologically similar. We propose that the early Homo specimen forms part of an archaic component in the fauna, in parallel with the other archaic faunal elements at Uitzoek. This supports an emergent pattern of archaic survivors in the southern landscape at this time, but also demonstrates the presence of early Homo in the central plains of southern Africa, beyond the dolomitic karst areas.

Treatment of dermatofibroma sarcoma protuberans using modified Mohs micrographic surgery: no recurrences and smaller defects.

OBJECTIVES: The purpose of this study was to evaluate the use of modified Mohs micrographic surgery (MMS) for dermatofibroma sarcoma protuberans (DFSP) in a single institution by a single surgeon. METHODS: The authors conducted a retrospective analysis of 25 patients with DFSP who were treated with modified MMS over the past 19 years at Scripps Clinic. RESULTS: Of the 25 patients treated with modified MMS for DFSP, there were no identifiable recurrences. The mean follow-up time was 101 months. The defect sizes of DFSP lesions treated by modified MMS are smaller than if the lesions had been treated with the standard wide local excision (WLE) margins of 3 cm. LIMITATIONS: This is a retrospective analysis using the data of one surgeon. Five of the 25 patients were not examined in our office. Not all patients had 5-year follow-up. There were no cases of the fibrosarcomatous variant. CONCLUSION: Our data support the growing literature that modified MMS achieves excellent local control for DFSP with a possible benefit of smaller defects when compared with treatment with WLE. The authors have indicated no significant interest with commercial supporters.

Anterior cervicoplasty: Neck rejuvenation using local anesthesia.

There is a subset of male patients that is troubled by redundant midline skin of the neck. Such patients may not be interested in having a face lift; they simply want elimination of the "turkey neck" appearance. Removal of redundant skin and underlying tissue can produce excellent results. We report our use of anterior cervicoplasty consisting of submental excision, midline platsymal placation and cutaneous Z-plasty using only minimal oral sedation and local anesthesia. This procedure can be a safe alternative to a face-lift for a select group of patients.

What specialties perform the most common outpatient cosmetic procedures in the United States?

BACKGROUND: The number of cosmetic procedures performed annually is on the rise and is being performed by more specialties. PURPOSE: We sought to determine the relative outpatient cosmetic procedure experience of dermatology and other specialties. We also examined demographic data of patients who underwent cosmetic procedures. METHODS: Demographics and data from the National Ambulatory Medical Care Survey (NAMCS) were analyzed to estimate the number of visits for office-based cosmetic procedures from 1995 to 2003 by specialty and type of procedure. RESULTS: In order of decreasing frequency, the percentage of all cosmetic procedures performed in the outpatient setting by specialty was as follows: dermatology (48%), plastic surgery (38%), general surgery (>4%), otolaryngology (>3%), ophthalmology (>3%), facial plastic surgery (1%), family practice (<1%), pediatrics (<1%), and internal medicine (<1%). Most cosmetic procedures were performed on white, female patients in the 40- to 59-year-old age group. There was a mean of 55 visits per 1,000 whites and 27 visits per 1,000 nonwhites. Chemical peels and soft tissue fillers were the two most common procedures. CONCLUSIONS: Dermatology as a specialty performs more office-based cosmetic procedures than other specialties. On a per-physician basis, dermatologists and plastic surgeons have far more experience with cosmetic procedures than other physicians.

Treatment of severe cutaneous ulcerative lichen planus with low molecular weight heparin in a patient with hepatitis C.

The ulcerative variant of lichen planus (LP) commonly involves the oral mucosa but is uncommon and difficult to treat when located on other areas. We describe an unusual case of ulcerative LP involving several surfaces, including the palms and scrotum, in a 50-year-old man with hepatitis C. The patient was recalcitrant to treatment with conventional therapy but obtained clearance with a sustained response using low molecular weight heparin (LMWH). This treatment is an option for patients with LP who are not ideal candidates for standard therapy.

Perineal ulcers in an infant: an unusual presentation of postnatal cytomegalovirus infection.

Cytomegalovirus (CMV) disease can cause significant morbidity and mortality in neonates and immunosuppressed patients. Cutaneous disease is rare, even in at-risk patients. We report a case of CMV with perineal papules, erosions, and ulcers in a preterm but presumably immunocompetent patient, whose diagnosis was first suggested by skin biopsy and confirmed with serologic testing. The mode of transmission of CMV was unclear. The lesions resolved without CMV-specific therapy, and the child had no apparent systemic sequelae of infection. CMV disease should be considered in the differential diagnosis of perineal erosions and ulcers in infancy. In addition to the case, we briefly review the literature on cutaneous manifestations of CMV disease.

The extent of dermatopathology education: a comparison of pathology and dermatology.

An indispensable component of all pathology and dermatology residencies is obtaining proficiency in the area of dermatopathology. The purpose of this study is to quantify dermatopathology training in pathology and dermatology residencies and the amount of continuing medical education in dermatopathology in leading journals of both fields. Dermatology residents complete more hours of dermatopathology than pathology residents. There is also more dermatopathology in the dermatology literature than in the pathology literature. Dermatopathology falls into the scope of both pathology and dermatology practice.

Limited availability of psoriasis and phototherapy care: an analysis of advertisements.

Because the number of dermatologists remains stable, patients with medical dermatologic conditions such as psoriasis may find it increasingly difficult to access dermatological treatment. Measuring the competition in the marketing of dermatologic care may provide insight into the availability of dermatology services. The purpose of this study was to determine to what extent dermatologists are using the Yellow Pages to advertise to patients with psoriasis. We performed a quantitative and qualitative assessment of dermatologists' Yellow Pages advertisements in small cities and the ten largest metropolitan regions in the country. Per capita, more advertisements were found in smaller markets than larger markets and a higher percentage was descriptive rather than just a name, address and phone number. Cosmetic and surgical advertisements were more common than psoriasis ads in both markets. Cosmetic ads were more prevalent in larger markets. In all regions, psoriasis and psoriasis treatment ads were least common. These findings raise the concern that incentive structures in the United States healthcare system do not adequately support delivery of dermatologic care for psoriasis. Efforts to promote psoriasis care should be encouraged.

Interpretation of dermatopathology specimens is within the standard of care of dermatology practice.

BACKGROUND: Laws have been passed in New York, California, New Jersey, Nevada, Louisiana, and Rhode Island and were recently tabled in South Carolina to prohibit providers from billing for pathology services provided by other physicians. The Ohio proposal included language stating that only board-certified pathologists be able to directly bill for anatomic pathology services. Dermatologists, however, have extensive training in dermatopathology and frequently bill anatomic pathology codes. OBJECTIVE: To determine if interpretation of cutaneous pathology falls within the standard of care of dermatology practice. DESIGN: We used Medicare part A and B claims data from the Medicare Current Beneficiary Survey, 1992 to 2000. We identified surgical pathology claims by Current Procedural Terminology (CPT) code 88305 and those related to skin disease by the associated International Classification of Disease, 9th Revision (ICD-9), code. Weights were applied to obtain nationally representative estimates. The number of physicians in each specialty was obtained from American Medical Association estimates. RESULTS: Pathologists, independent laboratories and group practices, and dermatologists submitted 59%, 26%, and 13% of total claims, respectively. For skin-related diagnoses, pathologists, dermatologists, and independent laboratories and group practices performed 34.5%, 31.2%, and 32.8% of cases, respectively. Assuming that independent laboratory and group practice claims were performed entirely by pathologists, dermatologists and pathologists submitted 1,047 and 1,154 cases/physician, respectively. CONCLUSION: Dermatologists have extensive training in dermatopathology and interpret a large proportion of cutaneous specimens. Interpretation of anatomic pathology, in particular, skin and subcutaneous pathology specimens, falls within the scope of dermatology practice.

Lower adverse event and mortality rates in physician offices compared with ambulatory surgery centers: a reappraisal of Florida adverse event data.

BACKGROUND: A recent study using Florida adverse event data found an increased risk of mortality in offices as opposed to ambulatory surgical centers. A major limitation of Florida adverse event data is the lack of uniform collection of the number of cases performed. OBJECTIVE: The objective was to reassess the risk of mortality from physician office and ambulatory surgical center procedures using improved estimates of the numbers of cases performed in these settings. METHODS: Adverse incident reports from March 2000 to March 2003 were obtained from the Florida Board of Medicine. We used data from the National Ambulatory Medical Care Survey and from the Medicare Current Beneficiary Survey to estimate the number of office procedures in Florida for both the general and the Medicare populations. The number of procedures performed and the number of deaths in ambulatory surgical centers was obtained from the Florida Agency of Healthcare Administration for the years 2000 through 2002. These data were used to calculate adverse event and mortality rates. RESULTS: For physician offices, the adverse event rates and mortality rates calculated per 100,000 procedures from National Ambulatory Medical Care Survey data were 2.1 and 0.41, respectively, and 0.24 and 0.10 using Medicare Current Beneficiary Survey data. For ambulatory surgical centers, the mean adverse event rate was 4.4 and the mean mortality rate was 0.90. DISCUSSION: Florida's adverse event data do not show higher adverse event rates in physician offices compared with ambulatory surgical centers. Incident reporting and public availability of incidents are important, as is standardization of reporting rules for both adverse events and number of procedures performed in different settings.

The safety of office-based surgery: review of recent literature from several disciplines.

OBJECTIVE: To review recent literature pertaining to adverse outcomes and mortality associated with office-based surgery. STUDY SELECTION: Representative articles from the general and plastic surgery, medical, health regulatory, and dermatology literature. DATA EXTRACTION: Information regarding which surgical treatments should be performed, which specialties should perform them, what level of anesthesia is appropriate, and who should administer it was assessed, with particular attention to issues of patient safety. CONCLUSIONS: Office-based surgery is safe and cost-effective. We caution against attempts to prohibit or severely restrict this important aspect of medical care.

Why are there differences in the perceived safety of office-based surgery?

BACKGROUND: Office-based surgery has become an important method of health-care delivery, but there is controversy about its safety and which practitioners should perform it. Several states have already or are preparing to enact legislation regulating office-based surgery. OBJECTIVE: The objective was to discuss recent literature pertaining to the safety of office surgery and to discuss reasons why there are perceived differences in its safety. METHODS: The pertinent literature is reviewed. Results. The majority of studies suggest that office surgery is safe. A recent study that found to the contrary may have methodologic flaws. CONCLUSION: The medical and legislative community should seek to scientifically examine office surgery. Overregulation or loss of office surgery would have a tremendous impact on the management of skin cancers and the delivery of quality cosmetic and laser surgery.

Diagnosis and treatment of acne.

Acne can cause significant embarrassment and anxiety in affected patients. It is important for family physicians to educate patients about available treatment options and their expected outcomes. Topical retinoids, benzoyl peroxide, sulfacetamide, and azelaic acid are effective in patients with mild or moderate comedones. Topical erythromycin or clindamycin can be added in patients with mild to moderate inflammatory acne or mixed acne. A six-month course of oral erythromycin, doxycycline, tetracycline, or minocycline can be used in patients with moderate to severe inflammatory acne. A low-androgen oral contraceptive pill is effective in women with moderate to severe acne. Isotretinoin is reserved for use in the treatment of the most severe or refractory cases of inflammatory acne. Because of its poor side effect profile and teratogenicity, isotretinoin (Accutane) must by prescribed by a physician who is a registered member of the manufacturer's System to Manage Accutane-Related Teratogenicity program.

Adult onset folliculocentric langerhans cell histiocytosis confined to the scalp.

Langerhans cell histiocytosis (LCH) is a pleomorphic disease entity characterized by local or disseminated atypical Langerhans cells found most commonly in bone, lungs, mucocutaneous structures, and endocrine organs. Cutaneous disease occurs in approximately one quarter of all cases. Cutaneous findings include soft-tissue swelling, eczematous changes, a seborrheic dermatitis-like appearance, and ulceration. We report a rare case of LCH confined to the scalp with folliculocentric infiltrates. This 32-year-old male patient presented with follicularly based erythema, scale, and pustules unresponsive to topicals and oral antibiotics. The patient's lesions mimicked lichen planopilaris and folliculitis decalvans during the disease process. On hematoxylin and eosin stain, scalp biopsy showed a perivascular interstitial patchy lichenoid mononuclear cell infiltrate that focally abutted follicular infundibula. Prominent mononuclear cells having reniform nuclei were present, and immunoperoxidase stains for CD1a confirmed Langerhans cell differentiation. Serological and imaging workup failed to display systemic involvement.

Seasonal variation of dermatologic disease in the USA: a study of office visits from 1990 to 1998.

BACKGROUND: Seasonal variation has been demonstrated in many diseases, including certain skin diseases. OBJECTIVE: To determine whether there is seasonal variation in dermatologic office visits in the USA. METHODS: Data on dermatologic office visits were obtained from representative visits to outpatient physicians in the USA from the National Ambulatory Medical Care Survey from 1990 to 1998. Office visit seasonality was examined for all skin conditions, and individually for the 15 most commonly diagnosed conditions. RESULTS: Office visits for skin conditions were seasonal (P = 0.002). The magnitude of variation can be roughly expressed by the following scheme: actinic keratosis (P = 0.0001) > acne (P = 0.0001) > folliculitis (P = 0.002) > dyschromia (P = 0.01) > seborrheic keratosis (P = 0.04) > psoriasis (P = 0.07) > seborrheic dermatitis (P = 0.09). Visits for skin cancer, not otherwise specified (skin cancer NOS), atopic dermatitis, cysts, common wart, wart, not otherwise specified (wart NOS), rosacea, contact dermatitis, and benign tumors showed no significant seasonal variations or trends. CONCLUSIONS: Dermatologic office visits are seasonal, with visits for individual diseases varying in their magnitude of seasonality. This seasonal variation may be a result of biological and nonbiological variables.