Calcium Hydroxyapatite (CaHA) Indication for Hand Rejuvenation.

The recent approval in 2015 of Radiesse for injection into the hand by the FDA has spurred an increase in interest among patients and clinicians in nonsurgical hand rejuvenation using fillers. Application of the same techniques used to treat the face to the dorsum of the hands does not account for the unique nature of the skin and underlying anatomy, and can lead to suboptimal outcomes and an increased risk of adverse events such as the formation of nodules. Here, the authors discuss dilution strategies and injection techniques for hand rejuvenation using Radiesse for optimal patient safety and aesthetic outcomes.

Molecular typing of human platelet and neutrophil antigens (HPA and HNA).

Genotyping is an important tool in the diagnosis of disorders involving allo-immunisation to antigens present on the membranes of platelets and neutrophils. To date 28 human platelet antigens (HPAs) have been indentified on six polymorphic glycoproteins on the surface of platelets. Antibodies against HPAs play a role in foetal and neonatal alloimmune thrombocytopenia (FNAIT), post-transfusion purpura (PTP) and refractoriness to donor platelets. The 11 human neutrophil antigens (HNAs) described to date have been indentified on five polymorphic proteins on the surface of granulocytes. Antibodies to HNAs are implicated with foetal and neonatal alloimmune neutropenia (FNAIN), autoimmune neutropenia (AIN) and transfusion related acute lung injury (TRALI). In this report, we will review the molecular basis and techniques currently available for the genotyping of human platelet and neutrophil antigens.

Role of corticosteroid as a prophylactic measure in fat embolism syndrome: a literature review.

Despite a number of studies on steroid therapy as a prophylactic measure in fat embolism syndrome (FES), there is no universal agreement about its role in this critical situation. The present article attempts to search the available literature, and provides a more lucid picture to the readers on this issue. Seven articles (total 483 patients) were reviewed and analyzed. Total of 223 patients received steroid (methyl prednisolone sodium succinate), while the remaining 260 patients formed the control population. Among these subjects, 9 patients in steroid-receiving group and 60 patients in the control group developed FES (P < 0.05). The lack of uniformities in these studies, variable dose and single-center trial are the principal limitations and confuses the surgeons to have definite conclusion. Large-scale, more uniformly designed, multi-centered, randomized, prospective trials are needed to determine the correct situations and dosage in which steroids provide the maximum benefit (with the least possible risk).

[Bufexamac-induced pigmented purpuric eruption]. / Kontaktallergie durch Bufexamac unter dem Bild einer chronischen Pigmentpurpura.

We report on a case of a bufexamac-induced allergic contact dermatitis with hematogenous dissemination presenting with the clinical and histological picture of a pigmented purpuric eruption. To our knowledge this is the first report on a bufexamac-induced pigmented purpuric dermatosis. It represents a further example of the clinical variety of cutaneous side-effects caused by bufexamac.

Acoustic attenuation by contrast agent microbubbles in superficial tissue markedly diminishes petechiae bioeffects in deep tissue.

OBJECTIVE: To measure how ultrasound attenuation by contrast agent microbubbles (MBs) in superficial tissue affects petechiae creation in underlying deep tissue. MATERIALS AND METHODS: Studies using Sprague-Dawley rats were approved by the Animal Care and Use Committee. MBs were injected intravenously, and 12 ultrasound pulses (100 sinusoids of 1 MHz ultrasound per pulse) were applied through the skin overlying the hindlimb adductors at intervals of 10 or 60 seconds. In some groups, the skin was resected and immediately returned without re-establishing vascular connections. Muscle petechiae were counted. RESULTS: Applying ultrasound through unperfused skin after bolus and continuous intravenous MB injection yielded, respectively, 30-fold and 3.5-fold more petechiae than for perfused skin. Surprisingly, petechiae/mm2 decreased with a higher MB dosage [0.12 +/- 0.05 (1 x 10 MBs/g) vs. 0.04 +/- 0.02 (3 x 10 MBs/g)] when ultrasound was applied through perfused skin. In contrast, petechiae/mm2 was approximately proportional to MB dosage for unperfused skin [0.17 +/- 0.10(5) (1 x 10 MBs/g) vs. 0.42 + 0.14 (3 x 10(5) MBs/g)]. In comparison to MB-free controls, MB solutions in this concentration range reduced the peak-negative pressure of ultrasound by 65% to 85%. CONCLUSIONS: Acoustic attenuation by MBs in skin markedly reduces petechiae creation in deep muscle. Petechiae inhibition is dependent on [MB]2.1 and, therefore, dominates the otherwise proportional relationship between petechiae and [MB] in muscle. The drop of peak-negative pressure below a critical microvessel rupturing threshold is the probable mechanism for petechiae inhibition. These results indicate that high MB doses could, paradoxically, reduce the potential for petechiae creation and may have important bearing on the design of contrast ultrasound-based therapeutics.

Use of a novel pulse dye laser for rapid single-pass purpura-free treatment of telangiectases.

BACKGROUND: Purpura-free elimination of telangiectases with a single pass of a pulsed dye laser with a large spot has proved difficult. OBJECTIVE: The purpose of this report was to define parameters that achieve single-pass purpura-free telangiectasia reduction. MATERIALS: Thirty patients between the ages of 23 and 78 years were treated with a pulsed dye laser with a 10-mm spot and fluences ranging from 9 to 10 J/cm2. The macropulse width was 20 ms. Each macropulse was composed of eight pulselets. Treatments were carried out over facial areas with discrete telangiectases. RESULTS: Smaller telangiectases (<600 microm) showed transient bluing followed by stenosis. Larger vessels (600-10,000 microm) showed bluing but inconsistent closure. A second pass typically resulted in closure. CONCLUSION: A modified pulsed dye laser was capable of single-pass purpura-free reduction with a 10-mm spot size.

The new-generation, high-energy, 595-nm, long pulse-duration pulsed-dye laser improves the appearance of photodamaged skin.

BACKGROUND AND OBJECTIVES: Chronic sun-exposure results in five main changes to exposed skin: telangiectasia, hyperpigmentation, rhytides, enlarged pores, and sagging skin. Various laser and non-laser modalities have been used to improve sun-damaged skin. The pulsed-dye laser (PDL) has an unparalleled safety record and an ideal wavelength for treating the signs of photodamage. In this study, we investigate the ability of the long pulse-duration PDL to improve the appearance of photodamaged skin. STUDY DESIGN/MATERIALS AND METHODS: Ten subjects with cutaneous photodamage were treated with the high-energy, long pulse-duration PDL using fluences ranging from 8.0 to 10.0 J/cm(2), a 10-mm spot, and a 10-millisecond pulse-duration. Five subjects judged to have discrete solar lentigos or ephiledes were also treated to these lesions using a compression handpiece. Improvement was determined by blinded evaluation of photographs taken before and after the final treatment, and by subjects' self-evaluation 8 weeks following the final treatment. RESULTS: Subjects rated overall improvement as 65%, facial veins as 72% improved, hyperpigmentation 65% improved, enlarged pores 65% improved, and wrinkles 62% improved. Improvement was also determined by 3 physicians rating digital photographs and blinded as to which photos were pre- or post-treatment. They rated wrinkles as improved in 50% of photographs, veins as improved in 82%, diffuse redness as improved in 80%, pigmentary alterations as improved in 61.4%, and pore size as improved in 25%. CONCLUSIONS: The high-energy, long pulse-duration PDL improves photodamaged skin using non-purpuric settings.

Minor complications after mandibular third molar surgery: type, incidence, and possible prevention.

PURPOSE: The aim of this prospective study was to ascertain the incidence of minor complications after mandibular third molar surgery and to predict the risk of skin ecchymosis or mucosa petechiae related to the usage of an absorbable gelatin sponge. PATIENTS AND METHODS: One hundred and four patients subjected to surgical extraction of horizontally impacted lower third molars were selected and investigated by means of questionnaires and clinical examinations. The independent sample t test was used for numeric variables. The chi-square test was used for logistic variables to determine the association between variables, and thereafter stepwise logistical regression was used. RESULTS: The older group (> or = 30 years old), with deeply impacted teeth, and long operation times (> or = 10 minutes) were shown to have significantly higher swelling than the other groups (P < .05). The patients who had deeply impacted teeth or long operation times were shown to have significantly higher VAS scores compared to short operation times (P < .05). The use of an absorbable gelatin sponge in the extraction socket significantly decreased postoperative swelling, mucosal petechiae, and skin ecchymosis (P < .05). CONCLUSION: The clinical variables related to postoperative bleeding disorder, pain, and trismus were identified. The insertion of an absorbable gelatin sponge into the extraction socket was found to be a very useful method to prevent postoperative bleeding problems.

Increase of dermal blood volume fraction reduces the threshold for laser-induced purpura: implications for port wine stain laser treatment.

BACKGROUND AND OBJECTIVES: The average success rate in achieving total blanching of port wine stain (PWS) lesions treated with laser-induced selective photothermolysis is below 25%, even after multiple treatments. This is because smaller diameter (5-20 microm) PWS blood vessels are difficult to destroy with selective photothermolysis since the volumetric heat generated by absorption of laser light is insufficient to adequately heat the entire vessel wall. The aim of this study was to investigate a potential technique for more efficient photocoagulation of small diameter PWS blood vessels in PWS that respond poorly to selective photothermolysis. STUDY DESIGN/MATERIALS AND METHODS: The blood volume fraction (BVF) in the upper dermis of the forearm of human volunteers was increased by placing an inflated blood pressure cuff on the upper arm. Applied pressures were in the range of 80-100 mm Hg for up to 5 minutes. The increased BVF was determined by matching reflectance spectra measured with that computed using a diffusion model. The impact of increased BVF on purpura formation induced by a 0.45 milliseconds pulsed dye laser (PDL) at 585 nm wavelength was investigated in normal and in PWS skin. RESULTS: In the presence of a 100 mm Hg pressure cuff, the BVF, as determined from the diffusion model, increased by a factor of 3 in the forearm and by 6 in the hand. Increasing BVF by a factor of 3 corresponds to an increase in blood vessel diameters by a factor of radical 3 approximately 1.7. BVF increased at 1-3 minutes after application of the pressure cuff, remained constant at 3-5 minutes, and returned to baseline values at 3 minutes after removal of the pressure cuff. Approximately 40% less radiant exposure was needed to induce the same amount of purpura after PDL irradiation when the blood pressure cuff was used. Applying an 80 mm Hg pressure cuff reduced the required radiant exposure for purpura formation by 30%. Heating of blood vessels was calculated as a function of vessel diameter and of radiant exposure (at 585 nm and at 0.5 and 1.5 milliseconds pulse duration). CONCLUSIONS: Enlarging the vessel lumen, for example, by obstructing venous return, can significantly reduce the "small-vessel-limitation" in PDL treatment of PWS. Dilation of PWS blood vessels enables a more efficient destruction of smaller vessels without increasing the probability of epidermal damage.

Treatment of vascular lesions using the VersaPulse variable pulse width frequency doubled neodymium:YAG laser.

BACKGROUND: The flashlamp-pumped dye laser is considered the treatment of choice for vascular lesions including port-wine stains. However, this treatment is associated with an intensive postoperative purpura and considerable pain. OBJECTIVE: We tested a newly developed laser device with a 532-nm neodymium:YAG laser with variable pulse widths between 2 and 10 ms. METHODS: Forty-two consecutive patients from our laser clinics were treated with the new laser system delivering energy through a chilled tip by means of circulating water (cooling temperature was between 4 and 5.5 degreesC). Forty of them had been pre-treated with an argon laser and an argon-pumped dye laser. RESULTS: Out of the 42 patients, 1 patient had a complete clearing, 11 had an excellent result (more than 80% clearing), 21 patients had a good result (51-75% clearing), weak responses were seen in 9 patients. Significant success was already seen after 1 or 2 treatments. Side effects were rare. There was no purpura after treatment. Local anesthesia was only applied in 6 out of 42 patients. CONCLUSION: The variable pulse width frequency doubled neodymium:YAG laser seems to be an alternative to the flashlamp-pumped dye laser and deserves to be investigated in comparative trials.

Treatment of facial telangiectases with the diode-pumped frequency-doubled Q-switched Nd:YAG laser.

BACKGROUND: Many individuals develop telangiectases on the face as they mature. The causative factors are numerous. Telangiectases are cosmetically concerning for many of those who are affected. Because of the ability to selectively target vessels, lasers have recently become the focus for treating small facial telangiectases. OBJECTIVE: The purpose of this study was to evaluate the efficacy of the diode-pumped frequency-doubled Q-switched neodymium: ytterium-aluminum-garnet (FD QSNd:YAG) laser (532 nm) for the treatment of telangiectases on the face. METHODS: The diode-pumped FD QSNd:YAG laser (532 nm, 400-micron spot size, 24-msec pulse train) was used to treat telangiectases on the face of 30 adult subjects. Patients were treated once, and clinical improvement and potential adverse effects were assessed at 4 and 8 weeks after treatment. RESULTS: One session of diode-pumped FD QSNd:YAG laser treatment either improved or totally cleared all treated facial telangiectases. CONCLUSION: The diode-pumped FD QSNd:YAG laser is effective for treating small facial telangiectases. An advantage of this laser is that it does not produce postoperative purpura.

Comparative efficacy of oral rifampin and topical chloramphenicol in eradicating conjunctival carriage of Haemophilus influenzae biogroup aegyptius. Brazilian Purpuric Fever Study Group.

Persistent conjunctival carriage of the Haemophilus influenzae biogroup aegyptius (Hae) strain (BPF clone) responsible for Brazilian purpuric fever (BPF) has been documented. Topical chloramphenicol is routinely used to treat conjunctivitis in areas affected by BPF in Brazil. Although the BPF clone is susceptible to chloramphenicol, we observed a number of children treated with topical chloramphenicol for conjunctivitis who still developed BPF. During an investigation of an outbreak of BPF in Mato Grosso State, Brazil, we compared oral rifampin (20 mg/kg/day for 4 days) with topical chloramphenicol for eradication of conjunctival carriage of H. influenzae biogroup aegyptius among children with presumed BPF clone conjunctivitis. Conjunctival samples were taken for culture on the day treatment was initiated and a mean of 8 and 21 days later. At 8 days the eradication rates for oral rifampin and topical chloramphenicol were 100 and 44%, respectively (P = 0.003); at 21 days they were 100 and 50% (P = 0.01). Oral rifampin was more effective than topical chloramphenicol for eradication of the BPF clone and may be useful in prevention of BPF.

Antibody to a 145-kilodalton outer membrane protein has bactericidal activity and protective activity against experimental bacteremia caused by a Brazilian purpuric fever isolate of Haemophilus influenzae biogroup aegyptius. The Brazilian Purpuric Fever Study Group.

The immunologic basis for protection against Brazilian purpuric fever, a septicemic infection associated with Haemophilus influenzae biogroup aegyptius bacteremia, is unknown. Passive immunization of infant rats with antiserum to whole bacterial cells of the homologous strain protects them from experimental bacteremia following bacterial challenge. In immunoblotting, antibody to a 145-kDa protein (P145) was present in protective antisera but not in nonprotective antisera. As judged by analysis of the antibodies eluted from whole bacterial cells and the agglutination of bacteria by antisera to P145, this protein is surface exposed. We prepared monospecific rat antisera to this protein by three methods: (i) immunization with whole bacterial cells and absorption with a Brazilian purpuric fever strain not expressing P145, (ii) immunization with gel-purified P145, and (iii) immunization with a P145-expressing transformant of a laboratory H. influenzae strain expressing this protein and absorption of the antiserum with the laboratory H. influenzae strain. These antisera had low antilipooligosaccharide antibody titers, were reactive only with P145, and had bactericidal activity in vitro. Following passive immunization, these antisera partially protected infant rats from bacteremia resulting from intraperitoneal challenge with bacteria. As assessed by immunoblotting, pooled adult human sera contained antibodies reactive with P145. Antibody to P145 may contribute to protection against Brazilian purpuric fever.