Interpersonal functioning and body image dissatisfaction in patients referred for NHS aesthetic surgery: A mediating role between emotion regulation and perfectionism?

BACKGROUND: Few studies have explored psychological factors associated with body image dissatisfaction in individuals seeking aesthetic surgery on the NHS. In NHS Scotland, The Adult Exceptional Aesthetic Referral Protocol (AEARP) states that individuals are only eligible for consideration for surgery where there is significant psychological distress and physical criteria associated with perceived problem of appearance. The AEARP necessitates that individuals seeking aesthetic surgery on the NHS must have a psychological assessment. It is therefore crucial to identify psychological factors associated with body image dissatisfaction that may highlight contraindications for surgery or are amenable to psychological intervention. METHOD: A total of 311 consecutive patients seeking aesthetic surgery who were referred for psychological assessment under the AEARP completed a series of psychometric measures as part of routine clinical practice. Multiple mediation analyses using bootstrapped method was used to explore the relationship between interpersonal functioning, emotion regulation, perfectionism, and body image dissatisfaction. RESULTS: Multiple mediation analysis indicated that emotion regulation partially mediates the relationship between interpersonal functioning and body image dissatisfaction in this clinical population. CONCLUSION: This study indicates that interpersonal functioning and emotion regulation significantly relate to body image dissatisfaction in this patient group. Psychological assessment of patient suitability for aesthetic surgery should include assessment of interpersonal functioning and emotion regulation which may be amenable to psychological intervention and be of significant benefit to patients either pre- or post-operatively or instead of surgery.

A bruise-like patch in a 4-year-old girl.

Dermatofibrosarcoma protuberans (DFSP), a rare medium grade sarcoma, occasionally occurs in childhood and is even more rarely present at birth. In children, the clinical appearance may be mistaken for a vascular malformation and so delayed diagnosis is not uncommon. Dermatofibrosarcoma protuberans is locally invasive and notorious for its high recurrence rate even after attempted wide local excision owing to extensive subclinical and asymmetrical extensions. In adult DFSP, Mohs Micrographic Surgery (MMS) is the treatment of choice because it offers a higher clearance rate compared to wide local excision. However, MMS may result in extended operating times owing to tissue processing and multiple stages. In children, this means a prolonged period under general anesthetic, which may be undesirable. We describe an interesting case of a 4- year-old girl diagnosed with DFSP. She underwent a modified MMS procedure in which she had two short general anesthetics. The advantage of MMS technique in which the full peripheral and deep margin of the specimen was examined.

Measures of health-related quality of life in diabetes-related foot disease: a systematic review.

AIMS/HYPOTHESIS: Patient-reported outcome measures (PROMs) are increasingly used as key performance indicators in chronic illness. We sought to review the value of these tools in assessing health-related quality of life (HRQOL) in patients with diabetes-related foot disease and identify the impact of each foot problem on life quality. METHODS: A systematic review of literature on HRQOL PROMs in diabetes-related foot disease was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The quality of eligible studies was evaluated within pre-existing criteria. RESULTS: 53 studies written between 1995 and 2010 met the inclusion criteria. A variety of HRQOL PROMs were used. Disease-specific tools were better than generic at quantifying temporal changes in life quality and showed greater sensitivity to ulcer/neuropathic severity. No studies have simultaneously evaluated disease-specific tools. Generic and utility HRQOL PROMs are frequently used as secondary outcome measures in randomised trials and cost-utility analysis. HRQOL is depressed in diabetes, further impaired by the presence of foot disease. Ulcer healing is associated with improvements in HRQOL. Patients with active ulceration report poorer HRQOL than those whom have undergone successful minor lower extremity amputation (LEA) but there is a paucity of quality data on HRQOL outcomes for diabetes-related LEA. CONCLUSIONS/INTERPRETATION: No one PROM was identified as a 'gold standard' for assessing HRQOL in diabetes-related foot disease. Specific areas for further development include the most valid HRQOL PROM with disease-specific content; HRQOL outcomes in minor and major amputations and the role of HRQOL tools in routine clinical care.

Vacuum-assisted closure and primary cutaneous aspergillosis in a burn - a management dilemma!

The advent of vacuum-assisted closure (VAC) devices has changed many wound management practices by application of topical negative pressure. A 20-year-old male sustained 21% total body surface area circumferential full-thickness burns to both legs from knees to feet. The VAC dressing was used in the management of his wounds. The patient had persistent pyrexia and graft destruction and subsequently the wounds cultured Aspergillus fumigatus. The increasing popularity of the VAC dressing is well deserved in the management of complex burn wounds. This case highlights the fact that in the care of complex burn patients the development of opportunistic infections should be considered, especially in situations such as persistent pyrexia or following the breakdown of healed grafts, particularly during the use of topical negative pressure.

The timing of autologous latissimus dorsi breast reconstruction and effect of radiotherapy on outcome.

INTRODUCTION: The optimal timing of breast reconstruction is controversial. Immediate breast reconstruction (IBR) has been gaining in popularity due to the aesthetic and psychological benefits, although its role is less certain when postoperative radiotherapy may be required. There is some evidence that long term cosmetic outcome of IBR using the autologous latissimus dorsi (ALD) flap may be impaired if the reconstruction is subjected to postoperative radiotherapy. We compared the long term cosmetic outcome and patient satisfaction between a group of patients who underwent IBR with postoperative radiotherapy and a group who underwent delayed ALD reconstruction. METHODS: Patients who underwent ALD breast reconstruction between 1997 and 2000 were invited to attend a research clinic. At the clinic up-to-date photographs were obtained and a quality of life questionnaire was completed. Cosmetic outcome was assessed by a panel of judges including surgeons, nurses and lay people. RESULTS: Thirteen patients who had IBR and postoperative radiotherapy and 11 patients who had delayed reconstruction attended for follow up. In the long term both groups fell within an acceptable cosmetic outcome range. However, there was a trend towards a better outcome in patients undergoing delayed reconstruction, with the volume and contour of the upper pole being most affected in the irradiated reconstructions. Patient satisfaction was similar between the two groups, however most patients in retrospect would have preferred an immediate reconstruction. CONCLUSIONS: Immediate ALD breast reconstruction, even in the setting of postoperative radiotherapy, yields satisfactory results. We continue to offer it to patients undergoing mastectomy operations, even when postoperative radiotherapy is likely to be required.

The efficacy of donepezil in the treatment of neuropsychiatric symptoms in Alzheimer disease.

OBJECTIVE: To determine the efficacy of donepezil in the treatment of neuropsychiatric symptoms in patients with Alzheimer disease (AD) in a randomized withdrawal study. METHOD: Patients with mild to moderate AD with marked neuropsychiatric symptoms at baseline (Neuropsychiatric Inventory [NPI] > 11 points) were treated openly with donepezil 5 mg daily for 6 weeks followed by 10 mg daily for a further 6 weeks. Patients were then randomized (60:40) to either placebo or 10 mg donepezil daily. All patients were assessed at 6 weeks and provided there was no marked cognitive deterioration their blinded treatment was continued for a further 6 weeks. NPI and carer distress were assessed at 6 weekly intervals throughout the study. RESULTS: A total of 134 patients participated. Following randomization patients who continued on donepezil 10 mg for 12 weeks had improvements in NPI compared with the placebo group (mean change -2.9 vs 3.3 points; ITT-LOCF p = 0.02) and in NPI-Distress scores (median change -2.0 vs 1.0 points; ITT-LOCF p = 0.01). During the open-label phase the total NPI and NPI-Distress scores were lower after 12 weeks treatment with open label donepezil compared with baseline (total NPI 22 points vs13 points; ITT-LOCF p < 0.0001; NPI-Distress 13.5 vs 7.9 points; ITT-LOCF p < 0.0001). In the open-label phase all domains of the NPI (with the exception of elation) were improved (all p < 0.05 after Bonferroni correction). CONCLUSIONS: Donepezil has significant efficacy in the treatment of neuropsychiatric symptoms in patients with mild to moderate AD.

Sebaceous carcinoma of the periorbital and extraorbital regions.

Sebaceous carcinomas are uncommon amongst cutaneous malignancies. These lesions can broadly be classified into 2 groups; (i) periorbital, which behave aggressively, and (ii) extraorbital, which are reported to metastasize rarely. A retrospective review has identified 12 cases of primary sebaceous carcinoma treated at Canniesburn Hospital over the decade from mid-1983 to mid-1993. Out of 7 cases with periorbital primary lesions, one patient died from metastatic disease and another developed local recurrence which was successfully excised. The series included an unusual case of metastasizing primary extraorbital sebaceous carcinoma.

Carpal tunnel syndrome: classic clinical symptoms and electrodiagnostic studies in poultry workers with hand, wrist, and forearm pain.

Carpal tunnel syndrome (CTS) has been linked to repetitive motion only in the past 15 years or so. Often the studies supporting this proposed link have not used strict clinical criteria and have rarely had electrodiagnostic confirmation of the diagnosis. In order to better assess the actual incidence of CTS in patients in a repetitive-motion job who had pain, numbness, tingling, or all three in the hand, wrist, or forearm, we examined 112 consecutive charts of such patients referred to a consulting neurologist for a possible diagnosis of carpal tunnel syndrome. Thirty-five percent of those patients had either classic clinical symptoms or positive electrodiagnostic results, but only half of these (17% of the total) actually had both. It is thus suggested that the incidence of CTS in patients doing repetitive motion may have been overestimated in the literature, and very strict clinical and electrodiagnostic criteria should be used before a diagnosis of carpal tunnel syndrome is made or surgery is contemplated in these patients.

Irregular discharge against medical advice from the accident and emergency department--a cause for concern.

An irregular discharge (ID) from the A&E department is an undesirable, but relatively common occurrence. A prospective study was undertaken to quantify the size of the problem and by arranging a subsequent review of the patient, to determine the clinical outcome. Over a 3-month period, 139 patients (0.73%) of attendances) took their own discharge against medical advice. A further 566 patients (3.03% of attendances) left prematurely prior to any medical assessment (DNW). Attenders irregularly discharged, often with serious untreated conditions. A high proportion were intoxicated with alcohol (65.5%). Attempted follow up proved difficult and incomplete. Patients with serious conditions appeared to return spontaneously for further care. Methods of minimizing the numbers of patients who take an ID or DNW are discussed. Taken together, the numbers of these attenders leaving prematurely, can be used as a valid performance indicator of the delivery of health care in the A/E department.

Median nerve latencies in poultry processing workers: an approach to resolving the role of industrial "cumulative trauma" in the development of carpal tunnel syndrome.

Much attention has been paid recently to a claimed connection between stressful repetitive motion at the work site and the development of carpal tunnel syndrome. Little of this has made its way into the widely appreciated medical literature. To try to discover a reasonable basis for the presence or absence of such an association we measured median nerve motor and sensory latencies in a random sample of employees in a medium industry of the kind thought to be associated with the emergence of carpal tunnel syndrome. A control group made up of applicants for positions of this sort was used. No association between employment experience and the development of slowing of the median motor latency was encountered in any group. No association was discovered for sensory latencies for men or for the left hands of women. A small association was discovered for the sensory latency in right hands of long-term female employees. This was similar in magnitude to the increased risk of prolongation associated with aging. Our data provide very little evidence for the concept of cumulative trauma as a prominent cause of carpal tunnel syndrome in American industry. These results are discussed in light of the recent Australian false epidemic of repetition strain injury.