Seizure and Interictal Electroencephalographic (EEG) Changes with Cannabinoid Concentrate Use.

BACKGROUND The electroencephalographic (EEG) findings associated with tetrahydrocannabinol (THC) use, particularly in concentrated form, are not well-described, despite the current widespread availability of these products. There is a lack of prior research describing the EEG findings in adolescent cannabis users, and the effects of THC on the seizure threshold have been variably reported. CASE REPORT A 17-year-old girl with no prior history of seizures or known seizure risk factors presented to an Emergency Department with acutely abnormal behavior in the setting of daily vaping of highly concentrated THC marijuana ("wax"). On admission, she had a witnessed generalized tonic-clonic seizure. Urine toxicology was positive for THC, and an extensive evaluation for other etiologies of her encephalopathy was unrevealing. Extended EEG on admission showed mild diffuse background slowing with occasional bifronto-centrally predominant sharp and spike wave discharges. Seven days later, without interim antiseizure medications, a repeat extended EEG showed resolution of the previously seen interictal findings. CONCLUSIONS The clinical and EEG findings were temporally associated with the patient's use of concentrated THC and may represent a constellation of symptoms of a THC wax toxidrome. In this case, THC was associated with lowering the seizure threshold and triggering a provoked seizure in an adolescent with no prior evidence of seizure tendency. This case also suggests the possibility of THC concentrate itself generating epileptiform discharges, as has previously been described with synthetic cannabinoid use.

Medical student healthcare consulting groups: A novel way to train the next generation of physician-executives.

Meeting the challenges of the evolving healthcare environment requires leadership of physicians well-trained in clinical medicine and healthcare management. However, many physicians lack training in business and leadership. While some residency programs have management tracks, training at the medical school level is currently lacking. We developed the Hopkins Health Management Advisory Group, an extracurricular program at Johns Hopkins University School of Medicine that exposes medical students to healthcare management and fosters development of leadership skills. Teams of students work directly with health system executives on 3-6 month-long projects using management consulting principles to address problems spanning health system domains, including strategy, operations, and quality improvement. Since the program's inception, 23 students have completed seven projects, with 13 additional students currently working on three more projects. Sponsors leading six out of seven completed projects have implemented recommendations. Qualitative survey respondents have found the program beneficial, with students frequently describing how the program has helped to develop professional skills and foster knowledge about healthcare management. These early assessments show positive impact for both students and the institution, and suggest that such programs can train students in management early and concurrently in their medication education by immersing them in team-based health system projects.

Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States.

Importance: Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population-based incidence in the United States. Objective: To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. Design, Setting, and Participants: This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. Main Outcomes and Measures: Incident skin cancer was determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). Results: Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). Conclusions and Relevance: Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.

Anatomical Basis for Safe and Effective Volumization of the Temple.

BACKGROUND: One of the earliest but often unaddressed signs of facial aging is volume loss in the temple. Treatment of the area can produce satisfying results for both patient and practitioner. OBJECTIVE: Safe injection requires explicit knowledge of the anatomy to avoid complications related to the multitude of vessels that course throughout the region at various depths. The authors aim to detail the anatomy of the area and provide a safe and easy-to-follow method for injection. MATERIALS AND METHODS: The authors review the relevant anatomy of the temporal region and its application to cosmetic filler injections. RESULTS: The authors describe an easy-to-follow approach for a safe and effective injection window based on numerous anatomical studies. Injection in this area is not without risk, including potential blindness. The authors review the potential complications and their treatments. CONCLUSION: Hollowing of the temple is an early sign of aging that, when corrected, can lead to significant patient and practitioner satisfaction. Proper anatomically knowledge is required to avoid potentially severe complications. In this study, the authors present a reliable technique to safely and effectively augment this often undertreated area of the aging face.

Collagen Stimulators: Poly-L-Lactic Acid and Calcium Hydroxyl Apatite.

Over the last decade, many studies of the structural changes observed in the aging face (in bone, fat pads, facial ligaments, muscle, skin) have increased our understanding that facial rejuvenation is more complex and nuanced than simply filling lines and folds or cutting and lifting soft tissue and skin. This, in addition to the many new products introduced to the marketplace over the same period, has fueled the evolution of panfacial rejuvenation and restoration using fillers. This article discusses current techniques used with calcium hydroxylapatite and poly-l-lactic acid to safely and effectively address changes observed in the aging face.

Subacute cutaneous lupus erythematosus: a case report of Polypodium leucotomos as an adjuvant therapy.

Subacute cutaneous lupus erythematosus (SCLE) is an uncommon autoimmune disease that results in substantial photosensitivity of affected patients. Eruptions often are triggered or exacerbated by UV light (UVL) exposure. We present a case of a patient with SCLE who was moderately controlled with hydroxychloroquine sulfate but achieved near total remission of disease after the addition of oral Polypodium leucotomos supplement which has photoprotective effects on human keratinocytes. We report sustained clinical response with the use of P leucotomos in lupus and suggest that it may have future application in photosensitizing dermatoses.

A comparative trial comparing the efficacy of tacrolimus 0.1% ointment with Aquaphor ointment for the treatment of keratosis pilaris.

Keratosis pilaris is common, but little information exists regarding effective therapy for this sometimes clinically and often cosmetically troublesome disorder. This small pilot study compared the efficacy of Aquaphor ointment with tacrolimus ointment 0.1% and found that both were effective and well tolerated by patients.

The risk of growing skull fractures in craniofacial patients.

BACKGROUND/AIMS: Growing skull fractures (GSFs) are unusual sequelae of head injury in young children which have also been reported to occur after craniofacial procedures complicated by inadvertent durotomy. We reviewed the craniofacial experience in a single institution, detailing 180 cases of craniofacial surgery and suspected dural tears and their relationship to the subsequent development of GSFs. This experience was then compared to that of the pertinent published literature. METHODS: A retrospective review of the senior authors' craniofacial surgical experience from 2000 to 2007 was performed. This was compared to an English-language literature review of GSFs after craniofacial surgery. RESULTS: In our institution, 180 cases of craniofacial surgery (83 open, 97 endoscopic) were performed, with an average follow-up of 23.5 months. Twenty-five patients (15 open, 10 endoscopic surgeries) had operative dural compromise. One of these patients developed a persistent pseudomeningocele requiring reoperation. Twelve cases of GSF after craniofacial surgery were identified in a review of the English-language literature, of which 7 (58%) had coronal suture fusion. CONCLUSIONS: While durotomy may occur during craniofacial surgery, the subsequent development of a GSF appears to be an unlikely event with an aggressive intraoperative approach of identification and repair. Coronal craniosynostosis may confer an increased risk for this complication.

Review of bone substitutes.

Bone substitutes are being increasingly used in craniofacial surgery and craniomaxillofacial trauma. We will review the history of the biomaterials and describe the ideal characteristics of bone substitutes, with a specific emphasis on craniofacial reconstruction. Some of the most commonly used bone substitutes are discussed in more depth, such as calcium phosphate and hydroxyapatite ceramics and cements, bioactive glass, and polymer products. Areas of active research and future directions include tissue engineering, with an increasing emphasis on bioactivity of the implant.

An important difference between "exposed" and "photodistributed" underscores the importance of identifying common reactions.

This article presents the case of a patient with rheumatoid arthritis who was referred to dermatology for what was suspected to be a photosensitivity reaction to hydroxychloroquine, a common culprit in photodrug reactions. Despite the patient's insistence to the contrary, the cause of her eruption was an airborne allergic contact dermatitis to chemicals she was exposed to during her longtime hobby of soap-making. This case serves as an important illustration of the anatomical differences between eruptions occurring in exposed and photodistributed areas. This article also discusses the causes of dermatitis that may mimic photodrug reactions.

Thimerosal and the relevance of patch-test reactions in children.

Thimerosal (C(9)H(9)HgNaO(2)S) is a mercuric derivative of thiosalicylic acid that goes by many names. It has been used as a disinfectant (eg, Merthiolate) and as a preservative in some vaccines, cosmetics, tattoo inks, eye drops, and contact lens solutions. It remains one of the least likely chemicals to cause contact allergy and for this reason has been removed from many standard screening series. Positive patch-test reactions (demonstrating sensitization) may still be seen (especially in older children); however, these reactions are not clinically relevant and are expected to be fewer, reflecting changes in current vaccine formulations.

Swimmer's nose deformity.

This is the first published report of the swimmer's nose deformity. This common athletic deformity has a characteristic, asymmetric dorsolateral nasal hump that progressively develops over years during a competitive swimming career and persists after cessation of the sport. The cause is thought to be bone and soft tissue remodeling in response to repetitive trauma chronically inflicted by a swimmer's goggles during the water reentry phase of breathing.

Comparison of open versus minimally invasive craniosynostosis procedures from the perspective of the parent.

Craniosynostosis, or the premature closure of the sutures of the skull, has historically been repaired in an open manner and included extensive cranial reconstruction. In recent years, technological advancements have given surgeons the ability to perform repairs with minimal surgical invasion. With the advent of endoscopy and bioresorbable plates, recent reports [J Craniofac Surg 2002;13(4):578-82] have emphasized attempts at decreased morbidity. Recently, researchers have been able to compare the results of traditional open and minimally invasive techniques in 45 craniosynostosis cases, demonstrating decreased operating room time, blood loss, transfusions, complications, and hospital stay in minimally invasive patients [Clin Plast Surg 2004;31(3):429-42]. Many of the parameters comparing the 2 types of procedures are easily quantified and comparable, but a variety of other considerations, such as the parent's reaction to the stress of surgery, arise. The purpose of this study was to compare the effects of these surgical procedures on the parent's level of stress at the time of operation. To accomplish this, we measured stress postoperatively using the Parenting Stress Index-Short Form. Subjects undergoing surgical treatment of craniosynostosis were placed into 2 groups: open versus minimally invasive. To test for confounding factors, subjects were subcategorized for sex, parent's sex, ethnicity, and parent's marital status. Analysis of our data reveals a statistically significant decrease in total stress in the households of minimally invasive patients.

Developmental hearing loss eliminates long-term potentiation in the auditory cortex.

Severe hearing loss during early development is associated with deficits in speech and language acquisition. Although functional studies have shown a deafness-induced alteration of synaptic strength, it is not known whether long-term synaptic plasticity depends on auditory experience. In this study, sensorineural hearing loss (SNHL) was induced surgically in developing gerbils at postnatal day 10, and excitatory synaptic plasticity was examined subsequently in a brain slice preparation that preserves the thalamorecipient auditory cortex. Extracellular stimuli were applied at layer 6 (L6), whereas evoked excitatory synaptic potentials (EPSPs) were recorded from L5 neurons by using a whole-cell current clamp configuration. In control neurons, the conditioning stimulation of L6 significantly altered EPSP amplitude for at least 1 h. Approximately half of neurons displayed long-term potentiation (LTP), whereas the other half displayed long-term depression (LTD). In contrast, SNHL neurons displayed only LTD after the conditioning stimulation of L6. Finally, the vast majority of neurons recorded from control prehearing animals (postnatal days 9-11) displayed LTD after L6 stimulation. Thus, normal auditory experience may be essential for the maturation of synaptic plasticity mechanisms.