The "modified" winch stitch

BACKGROUND

The methods described to achieve intraoperative tissue expansion have drawbacks.

OBJECTIVE

To report an intraoperative tissue expansion technique using standard suture material and hemostats to create a "modified" winch stitch.

METHODS

A continuous running suture is placed with both ends left free. A "fixed" hemostat is placed above the skin at one end. After pulling at the other end with a second hemostat, a third hemostat is placed proximal to this hemostat just above the skin, which is left in place to produce stretching. The second and third hemostats are then used in an alternating pulling and holding fashion.

RESULTS

This method produces significant tissue expansion. If the desired degree of approximation is achieved, the ends of the suture can be tied together, as in the previously described winch stitch.

CONCLUSION

The modified winch stitch is a simple and inexpensive means to facilitate closure of wounds under a significant amount of tension.

Apocrine poroma of the breast

Poromas are sweat gland tumors classically reported to be of eccrine origin. However, it is now recognized that poromas may also be derived from apocrine glands. There are no prior reports of either type of poroma arising on the breast. We report the first case of a poroma of the breast. The lesion was localized to the areola of a 70-year-old woman and mimicked an underlying neoplasm of the breast. Because the histopathology demonstrated apparent continuity of a benign poroma with the infundibula of hair follicles, the diagnosis of apocrine poroma was made. The poroma in this case is of apocrine derivation. This report demonstrates that apocrine poromas should be considered in the clinical differential of acquired lesions on the areola, suggesting an underlying breast tumor. Apocrine poromas that are only partially biopsied may recur. Moreover, since apocrine poromas may potentially develop into apocrine porocarcinomas, analogous to eccrine poromas sometimes transforming into eccrine porocarcinomas, apocrine poromas should be completely excised.

Vitamin D: balancing cutaneous and systemic considerations

BACKGROUND

Vitamin D insufficiency may lead to various health problems. By encouraging sun protection to prevent skin cancer, physicians may be limiting a major source of vitamin D for many individuals.

METHODS

We did a literature review on issues related to vitamin D inadequacy, particularly those relevant to various racial/ethnic groups.

RESULTS

Vitamin D is an important hormone with many physiologic roles beyond those related to bones, including blood pressure regulation and acting as a tumor suppressant. The recommended amount of vitamin D has recently increased for adults over age 50. Moreover, some researchers are urging higher doses for the entire population to prevent osteoporotic fractures.

CONCLUSIONS

Previous studies that have found serum levels of vitamin D in their sun-protected subjects to be in the normal range may need to be reevaluated. In concert with counseling sun protection, physicians should consider discussing vitamin D intake, typically in the form of supplements.

Cutaneous Mycobacterium chelonae in a liver transplant patient

A 51-year-old woman with an orthotopic liver transplant on tacrolimus (SKF 506) and prednisone presented with an erythematous ulcerated nodule on the knee. No preceding trauma was noted. A skin biopsy specimen demonstrated beaded gram-positive, acid-fast rods and the skin culture grew Mycobacterium chelonae (formerly M chelonae subsp chelonae ). This report describes the first case in a liver transplant patient of cutaneous Mycobacterium chelonae under the current method of designating atypical Mycobacterium species.

Quinolones and tendon ruptures

We report two cases of tendon rupture associated with ciprofloxacin. One patient had a complete rupture of an Achilles tendon 6 months after taking the medication. The other case involved a partial rupture of the subscapularis tendon. Both ruptures occurred with minimal mechanical stress on the tendons, suggesting that the fluoroquinolone increased the susceptibility to rupture. We also review the literature describing the association between fluoroquinolones and tendon rupture and discuss the mechanisms explaining the heightened risk of tendon rupture associated with these drugs.

Using a side effect to therapeutic advantage: the darkening of red eyebrow tattoo pigment following Q-switched laser treatment

BACKGROUND

Q-switched lasers are commonly used to achieve tattoo removal, utilizing the principle of selective photothermolysis. However, certain tattoo pigments may darken following laser pulsing.

OBJECTIVE

To determine whether this side effect can be used to therapeutic advantage in a woman who previously had her eyebrows enhanced with a dark tattoo that spontaneously changed to a reddish hue over time.

METHOD

The woman's eyebrows were pulsed with the Q-switched Nd:YAG laser at both 532 nm and 1064 nm.

RESULTS

The test areas pulsed with the 1064 nm laser revealed partial clearing. However, 532 nm Q-switched Nd:YAG pulses produced darkening of tattoo pigment both at the test sites and in the subsequent treatment.

CONCLUSION

Q-switched lasers can produce darkening of red tattoo pigment. In some cases this side effect can be used to therapeutic advantage.

Analysis of pressure achieved by various materials used for pressure dressings

BACKGROUND

To minimize the risk of complications, pressure dressings are frequently applied to wounds. The actual pressures yielded by different dressing materials and application techniques have not been documented.

OBJECTIVE

To measure and compare pressures produced using various types of dressing tapes with and without a gauze roll.

METHODS

An infant blood pressure cuff was adapted for use in a pressure dressing model. Investigators independently applied four strips of each of five different types of tape to the cuff when it was located in three settings: a hard inanimate surface, a subject's distal volar forearm, and the subject's forehead.

RESULTS

Foam and plastic tapes produced more pressure under a simple dressing than three other commonly used tapes. Higher, more consistent pressures were achieved on the forearm than the forehead. Adding a gauze roll to the dressing consistently increased the pressure.

CONCLUSION

The experimental model demonstrated substantial differences in pressures yielded by various pressure dressing materials.

Neuroendocrine differentiation of a metastatic basal cell carcinoma in a patient with basal cell nevus syndrome

A 48 year-old white male with basal cell nevus syndrome presented with a metastatic basal cell carcinoma with neuroendocrine features. The tumor manifested aggressive behavior, having deep local invasion and metastases to para-aortic lymph nodes and bone. Neuroendocrine differentiation has rarely been associated with basal cell carcinoma. The histologic, immunohistochemical, and electron microscopic studies of this rare tumor are described.

Detection of human herpesvirus 8 DNA in Kaposi's sarcoma lesions and peripheral blood of human immunodeficiency virus-positive patients and correlation with serologic measurements

Polymerase chain reaction (PCR) was used to examine human herpesvirus 8 (HHV-8) DNA from Kaposi's sarcoma (KS) lesions, normal skin, and peripheral blood mononuclear cells (PBMC) from human immunodeficiency virus (HIV)-infected patients who did or did not have KS. Of 9 KS biopsies, 8 were positive for five HHV-8 open-reading frames and ranged from 1 viral genome per 2.5-12.7 cells. Two putative replicative gene RNAs were detected by reverse transcription-PCR at low levels in 1 KS lesion. HHV-8 DNA was detected in 4 of 8 PBMC samples from patients with KS and in 2 of 18 PBMC samples from patients without KS. Sera were tested for reactivity with BCBL-1 cells (HHV-8 positive): High immunofluorescence antibody titers against HHV-8 lytic and latent antigens were detected in samples from KS-positive patients, and >20 polypeptides from induced BCBL-1 cells were recognized. Sera from 6 of 18 patients without KS showed low levels of antibodies against HHV-8 lytic and latent antigens.

Thermal relaxation of port-wine stain vessels probed in vivo: the need for 1-10-millisecond laser pulse treatment

Although thermal relaxation times of cutaneous port-wine stain microvessels have been calculated and used to formulate laser selective photothermolysis, they have never been measured. A scheme to do so was devised by measuring the skin response to pairs of 585-nm dye laser pulses (250-360 microseconds each) as a function of the time interval between the two pulses, in five volunteers with port-wine stains. After a pump pulse delivering 80% of the fluence necessary for causing purpura, the fluence of a second probe pulse necessary to cause purpura was determined and was found to increase with the interval between the two pulses, in a manner consistent with thermal diffusion theory. Biopsy specimens were obtained from four of the five subjects to examine the nature and extent of vessel damage and to measure the port-wine stain vessel diameters. Using diffusion theory, the thermal relaxation time was calculated based on the measured vessel diameters. These calculated values are consistent with the increase in radiant exposure (fluence) of the probe pulse necessary to induce purpura for longer time delays. Two simple models for thermal relaxation of port-wine stain vessels are presented and compared with the data. The data and histologic assessment of the vessel injury strongly suggest that pulse durations for ideal laser treatment are in the 1-10-millisecond region and depend on vessel diameter. No dermatologic lasers presently used for port-wine stain treatment operate in this pulse width domain.

The inconsistent effects of calcium supplements upon blood pressure in primary hypertension

The effects of 800 mg of elemental calcium per day (calcium carbonate or calcium citrate) on blood pressure were compared with a placebo in a controlled randomized, crossover, double-blinded trial involving 26 patients with uncomplicated primary hypertension. Each patient took two of the three forms of therapy orally for 8-week intervals with a 2-week washout period in between. Standing mean blood pressure rose an average of 5.7 mm Hg on placebo, rose an average of 0.5 mm Hg on calcium carbonate, and fell an average of 2.2 mm Hg on calcium citrate. Changes in sitting mean pressures averaged +1.9 mm Hg on placebo, -0.4 mm Hg on calcium carbonate, and -0.4 mm Hg on calcium citrate. Some patients had a fall, others had a rise in blood pressure on each form of calcium. Similarly, inconsistent responses were noted among the nine patients who took both forms of calcium. Neither initial nor post-treatment biochemical measures nor patient characteristics were predictive of the blood pressure response. Combinations of various measures and characteristics analyzed by the multiple regression technique explained only 30% of the overall variability in blood pressure. Therefore, until ways can be found to predict the response, calcium supplements should not be routinely prescribed for the treatment of hypertension and, if given for any indication, blood pressure should be monitored.