Surgical planing of the skin; complications and reevaluation of indications

One hundred plastic planing operations on the skin by means of a motor-driven wire brush were reviewed. Complications noted were pruritic erythematous eczematous dermatitis on a possible autosensitization basis, hyperpigmentation and milia. These occurred in a small proportion of cases and in no case were they permanent sequelae. Flat postacne scarring is more easily improved than steep "ice-pick" type scars. The planing procedure is contraindicated in the management of certain tumors of the skin, portwine nevi, decorative tattoos, and generalized dermadromes. The psychiatric and emotional impact of the patient's scarring on his personality is often a great one and the operator must bear in mind that plastic planing is no panacea for a severely neurotic patient. Therefore it is important that patients be carefully selected and that improvement rather than complete cure be stressed.     

SKIN CLOSURE—A Disposable Atraumatic Instrument for Office Procedures

A disposable applicator with a suture clip bearing unusually fine spicules, which can be kept sterile in an envelope on an office shelf or in a physician''s bag, facilitates the carrying out of the cosmetic closure of skin lacerations and incisions as an office procedure.The spicules of the clips are so fine that they cause practically no bleeding when they are placed or removed. The needle-prick scarring and the “ladder” pattern caused by the placing of sutures with a needle are avoided.     

MANDIBULAR HERPES ZOSTER—With Report on the Use of Cortisone in a Case with Geniculate Ganglion Symptoms

Herpes zoster, an acute specific viral infection, occurs more commonly than is generally supposed. It should be differentiated from other diseases involving the ear and skin; it must be considered as a possible etiologic agent in some palsies of the facial, glossopharyngeal or vagal nerves.The type of cephalic herpes zoster should be carefully differentiated; cases involving the “geniculate zone” may be other than “Ramsay Hunt''s syndrome.” This syndrome is now defined as a herpes zoster eruption of the external ear at the “geniculate zone” with involvement of the seventh or seventh and eighth nerves.The “topognostic” method is the best for determining the level at which the facial nerve has been affected.It is questioned whether there is a single outstanding therapeutic agent for this disease. Cortisone had no apparent therapeutic effect in a case reported herein.     

Hospital Infections Caused by a Group of Recently Recognized Strains of Staphylococcus aureus

A survey was made of the phage-types of staphylococci responsible for cross-infection in a large veterans'' hospital between 1961 and 1964. An earlier survey had shown that in 1959 most of the infections were caused by staphylocci of the “80/81/82” group. In 1961 a new group of staphylococci were first recognized and provisionally designated as “Atypical Group III” strains; these were non-typable by the usual typing phages but showed inhibition patterns with some of the Group III phages. The “Atypical Group III” staphylococci all showed one or other of four patterns of multiple antibiotic resistance. By 1963 these resistant “Atypical Group III” staphylococci had become more frequent than “80/81/82” strains as causative agents of cross-infection, although both groups have continued to cause infections in the hospital. “Atypical Group III” strains mainly infected surgical wounds and skin ulcers, whereas “80/81/82” strains commonly produced primary skin sepsis, such as boils.     

Action of Deflocculating Agents on Saccharomyces cerevisiae Class III Brewer's Yeast

Earlier work with a fluorescent aid indicated that flocculent brewer''s yeast may have more surface lipids than nonflocculent types. Organic solvents were checked against flocculent Gilliland yeasts. It was found that those reagents which affect “free” lipids had no dispersive action, and those which remove “bound” fats had a powerful dispersive action against such yeasts. There was no indication that such an action could be correlated with other physical properties of the solvents. The uranyl ion is known for its ability to complex with phospholipids, and it was found to have a powerful dispersive action on Gilliland yeasts. Its effect was compared with that of glucose in its dispersion of yeast flocs, and possible cell “sites” were suggested. This, along with other work, suggests the possibility that lipids are directly or indirectly involved in yeast flocculation.     

Research of a holiday kind: A clinical trial gone awry: the Chocolate Happiness Undergoing More Pleasantness (CHUMP) study

The randomized controlled trial is the “gold standard” for evaluating the benefits and harms of interventions. The Chocolate Happiness Undergoing More Pleasantness (CHUMP) study was designed to compare the effects of dark chocolate, milk chocolate and normal chocolate consumption on happiness. Although the intention-to-treat analysis showed that participants who received either dark or milk chocolate were happier than those who received no additional chocolate, the actual-consumption analysis showed that there were no differences between any of the groups. The reason for this result is that many participants switched groups mid-study because of their personal chocolate preferences. Although the CHUMP study was pleasurable, it demonstrated the difficulties associated with performing a truly blinded clinical trial.The randomized controlled trial is the “gold standard” for testing the beneficial and harmful effects of interventions. There has been a growing concern in the literature about the potential for bias during randomization of participants in clinical trials.^1–5 I designed the Chocolate Happiness Undergoing More Pleasantness (CHUMP) study to compare the effects of dark chocolate, milk chocolate and “normal” chocolate consumption on happiness. The CHUMP study was a double-blinded clinical trial, and it demonstrated the difficulties associated with performing a truly blinded clinical trial.     

In-use Evaluation of Safety to Skin of Enzyme-Containing Washing Products

The effect on the skin of housewives of using a washing product in the home for all cleaning purposes under conditions of maximal exposure has been studied. Tests conducted on over 4,000 housewives showed that detergents containing proteolytic enzymes had no greater effect on the skin than conventional detergents, even when the hand skin condition was initially poor. The same was true in a further test on 130 housewives with “dishpan” hands. No adverse reactions attributable specifically to the enzyme products were seen. No eruptions from contact with clothes washed in enzyme products were reported from any of the families involved in these tests.     

Surgical planing of the skin; dichlorotetrafluoro-ethane as a freezing agent

Surgical skin planing is, in the hands of an experienced operator, a safe and highly effective procedure for treating a number of cutaneous defects, most notably pitted acne scars. The operation is facilitated by the use of a new instrument (jet-spray handpiece) which allows the operator to freeze the skin and plane it almost simultaneously, and by a new freezing agent, dichlorotetrafluoro-ethane, which adds to the safety by eliminating the old hazards of inflammability, explosion, and the toxic inhalation of ethyl chloride. The ability to sharply differentiate between keloid and hypertrophic scar is fundamental to surgical skin planing. A hypertrophic scar results from the removal or destruction of the cutaneous appendages (hair follicles, oil and sweat glands and ducts); whereas a keloid is an idiosyncratic response without regard to damage of the appendages.Properly performed surgical planing does not entirely remove these appendages and therefore healing occurs without scarring.     

Leprosy in a prison population: A new active search strategy and a prospective clinical analysis

BackgroundThis study evaluates an active search strategy for leprosy diagnosis based on responses to a Leprosy Suspicion Questionnaire (LSQ), and analyzing the clinical, immunoepidemiological and follow-up aspects for individuals living in a prison population.MethodsA cross-sectional study based on a questionnaire posing 14 questions about leprosy symptoms and signs that was distributed to 1,400 prisoners. This was followed by dermatoneurological examination, anti-PGL-I serology and RLEP-PCR. Those without leprosy were placed in the Non-leprosy Group (NLG, n = 1,216) and those diagnosed with clinical symptoms of leprosy were placed in the Leprosy Group (LG, n = 34).FindingsIn total, 896 LSQ were returned (64%), and 187 (20.9%) of the responses were deemed as positive for signs/symptoms, answering 2.7 questions on average. Clinically, 1,250 (89.3%) of the prisoners were evaluated resulting in the diagnosis of 34 new cases (LG), based on well-accepted clinical signs and symptoms, a new case detection rate of 2.7% within this population, while the NLG were comprised of 1,216 individuals. The confinement time medians were 39 months in the LG while it was 36 months in the NLG (p>0.05). The 31 leprosy cases who responded to the questionnaire (LSQ+) had an average of 1.5 responses. The symptoms “anesthetized skin area” and “pain in nerves” were most commonly mentioned in the LG while “tingling, numbness in the hands/feet”, “sensation of pricks and needles”, “pain in nerves” and “spots on the skin” responses were found in more than 30% of questionnaires in the NLG. Clinically, 88.2% had dysesthetic macular skin lesions and 97.1% presented some peripheral nerve impairment, 71.9% with some degree of disability. All cases were multibacillary, confirming a late diagnosis. Anti-PGL-I results in the LG were higher than in the NLG (p<0.0001), while the RLEP-PCR was positive in 11.8% of the patients.InterpretationOur findings within the penitentiary demonstrated a hidden prevalence of leprosy, although the individuals diagnosed were likely infected while living in their former communities and not as a result of exposure in the prison. The LSQ proved to be an important screening tool to help identify leprosy cases in prisons.     

Use of 4% Chlorhexidine Detergent Solution (Hibiscrub) and Other Methods of Skin Disinfection

In a comparison of three antiseptic detergent preparations for hand washing, Hibiscrub, a 4% chlorhexidine detergent solution, caused a significantly greater estimated immediate reduction of skin flora (86·7% ± 3·0) than was obtained with Dermofax, a 0·75% chlorhexidine detergent solution (55·5% ± 5·1), or with Disadine scrub, a povidone iodine detergent preparation (68% ± 6·8). After six applications the mean estimated reductions of skin flora were 99·2% ± 0·2 for Hibiscrub, 97·7% ± 0·7 for povidone iodine, and 91·8% ± 1·6 for Dermofax.After a series of hand washings with Hibiscrub, as with a hexachlorophane detergent preparation, a further large reduction of skin flora, shown by bacterial counts of hand sampling, was obtained by a second phase of disinfection consisting of two minutes'' application on gauze swabs of 0·5% chlorhexidine digluconate in 70% ethanol; a further wash with Hibiscrub, in place of alcoholic chlorhexidine, for the second phase of disinfection caused an increase rather than a reduction in the yield of bacteria on skin sampling. Unlike this “two-phase” disinfection, the application for 30 minutes of compresses soaked in 10% aqueous povidone iodine or in 0·5% aqueous chlorhexidine digluconate did not cause a greater reduction in skin flora than that obtained by the conventional two minutes'' application on gauze of 0·5% chlorhexidine in 70% ethanol.Chlorocresol (0·3%) liquid soap (the base used for Ster-Zac liquid hexachlorophane soap) caused a mean reduction of skin flora when used for hand washing of 29% after one application and 72% after six applications spread over two days. This formulation, though less active and more variable as a detergent skin antiseptic than chlorhexidine, hexachlorophane, or povidone iodine detergent preparations, is an inexpensive disinfectant soap which could be useful in catering establishments. Alcoholic cetrimide applied as for disinfection of an operation site caused a reduction of skin flora greater than that shown by aqueous cetrimide but comparable to that shown by 70% ethyl alcohol in previous experiments.     

GRADED ABRASION—A TREATMENT FOR ACNE

Long term continuous superficial abrasion with abrasive compounds of various degrees of roughness was used over an 11-year period in over 1,500 patients with acne of all types. The following observations were made:• That when a material with a specific abrasive quality is used for a period, desquamation stops despite continued use of the material, and then use of material of the next higher degree of roughness is indicated until the patient''s skin is blackhead-free and minutely flaky.• When long term continuous superficial graded abrasion is used alone or with other treatment, it permits the young patients to outgrow the disease with little or no scarring.• The routine of abrasive washing seems in a large measure to replace the constant fingering of lesions by the patient.• No untoward effects were observed clinically. There was no hyperpigmentation of Negro or Caucasian skins.     

Methoxyflurane and Nitrous Oxide as Obstetric Analgesics. I.—A Comparison by Continuous Administration

Methoxyflurane and nitrous oxide have been compared as obstetric analgesics. The inhaled concentrations of these agents, given continuously, were adjusted by an anaesthetist to maintain each patient at the optimum state between reaction to pain and consciousness. Assessments were made continuously.Though the anaesthetist''s assessment showed no difference between the mean results, a greater proportion of the methoxyflurane patients were “satisfactory” for 90–100% of the time than of the nitrous oxide patients, particularly in regard to objective pain relief. The midwives'' opinion of those who had “complete” pain relief supported this. Nausea was significantly less among methoxyflurane patients, and vomiting during labour occurred only in patients who had nitrous oxide. It is concluded that nitrous oxide and methoxyflurane given in a continuously adjusted concentration are almost equally effective as obstetric analgesics, though there are certain features which favour methoxyflurane.     

Dichloro-tetrafluoro-ethane as a Freezing Agent

Surgical skin planing is, in the hands of an experienced operator, a safe and highly effective procedure for treating a number of cutaneous defects, most notably pitted acne scars.The operation is facilitated by the use of a new instrument (jet-spray handpiece) which allows the operator to freeze the skin and plane it almost simultaneously, and by a new freezing agent, dichlorotetrafluoro-ethane, which adds to the safety by eliminating the old hazards of inflammability, explosion, and the toxic inhalation of ethyl chloride.The ability to sharply differentiate between keloid and hypertrophic scar is fundamental to surgical skin planing. A hypertrophic scar results from the removal or destruction of the cutaneous appendages (hair follicles, oil and sweat glands and ducts); whereas a keloid is an idiosyncratic response without regard to damage of the appendages.Properly performed surgical planing does not entirely remove these appendages and therefore healing occurs without scarring.     

Practitioner attitudes in the United States and United Kingdom toward decisions at the end of life: are medical ethicists out of touch?

Objective To assess whether UK and US health care professionals share the views of medical ethicists about medical futility, withdrawing or withholding treatment, ordinary or extraordinary interventions, and the doctrine of double effect. Design, subjects, and setting Answers to a 138-item attitudinal questionnaire completed by 469 UK nurses studying the Open University course on “Death and Dying” were compared with those of a similar questionnaire administered to 759 US nurses and 687 US physicians taking the Hastings Center course on “Decisions Near the End of Life.” Results Practitioners accept the relevance of concepts widely disparaged by bioethicists: double effect, medical futility, and the distinctions between heroic and ordinary interventions and withholding and withdrawing treatment. Within the UK nurses'' group, the responses of a “rationalist” axis of respondents who describe themselves as having “no religion” are closer to the bioethics consensus on withholding and withdrawing treatment. Conclusions Professionals'' beliefs differ substantially from the recommendations of their professional bodies and from majority opinion in bioethics. Bioethicists should be cautious about assuming that their opinions will be readily accepted by practitioners.     

Are British urban foxes (Vulpes vulpes) “bold”? The importance of understanding human–wildlife interactions in urban areas

Human–wildlife interactions are believed to be increasing in urban areas. In Britain, numerous media reports have stated that urban foxes (Vulpes vulpes) are becoming “bolder,” thereby posing a risk to public safety. However, such claims overlook how an individual''s personality might influence urban fox behavior. Personality determines multiple aspects of an animal''s interactions with both conspecifics and its environment, and can have a significant impact on how people perceive wildlife. Furthermore, describing urban foxes as “bold” confounds two different but inter‐related behaviors, both of which influence an animal''s propensity to take risks. Neophobia affects an animal''s reaction to novelty, wariness its reaction to potential threats. Since urban wildlife frequently encounters both novel and threatening stimuli, a highly adaptable species such as the red fox might be predicted to exhibit reduced neophobia and wariness. We investigated how social status influenced both behaviors in Bristol''s fox population. Dominant foxes were significantly more neophobic and warier than subordinates, which adopt a more exploratory and risk‐taking lifestyle to meet their energetic and other needs. We found no seasonal effect on neophobia and wariness, although this may be due to sample size. The presence of conspecifics decreased neophobia for dominants, and wariness for both dominants and subordinates. We highlight the importance of considering animal social status and personality when planning management protocols, since interventions that destabilize fox social groups are likely to increase the number of subordinate foxes in the population, thereby increasing rather than decreasing the number of interactions between humans and urban foxes.     

Marine Plastic Pollution in Waters around Australia: Characteristics,Concentrations, and Pathways

Plastics represent the vast majority of human-made debris present in the oceans. However, their characteristics, accumulation zones, and transport pathways remain poorly assessed. We characterised and estimated the concentration of marine plastics in waters around Australia using surface net tows, and inferred their potential pathways using particle-tracking models and real drifter trajectories. The 839 marine plastics recorded were predominantly small fragments (“microplastics”, median length = 2.8 mm, mean length = 4.9 mm) resulting from the breakdown of larger objects made of polyethylene and polypropylene (e.g. packaging and fishing items). Mean sea surface plastic concentration was 4256.4 pieces km⁻², and after incorporating the effect of vertical wind mixing, this value increased to 8966.3 pieces km⁻². These plastics appear to be associated with a wide range of ocean currents that connect the sampled sites to their international and domestic sources, including populated areas of Australia''s east coast. This study shows that plastic contamination levels in surface waters of Australia are similar to those in the Caribbean Sea and Gulf of Maine, but considerably lower than those found in the subtropical gyres and Mediterranean Sea. Microplastics such as the ones described here have the potential to affect organisms ranging from megafauna to small fish and zooplankton.     

Adaptive Response to DNA-Damaging Agents in Natural Saccharomyces cerevisiae Populations from “Evolution Canyon”, Mt. Carmel,Israel

Background

Natural populations of most organisms, especially unicellular microorganisms, are constantly exposed to harsh environmental factors which affect their growth. UV radiation is one of the most important physical parameters which influences yeast growth in nature. Here we used 46 natural strains of Saccharomyces cerevisiae isolated from several natural populations at the “Evolution Canyon” microsite (Nahal Oren, Mt. Carmel, Israel). The opposing slopes of this canyon share the same geology, soil, and macroclimate, but they differ in microclimatic conditions. The interslope differences in solar radiation (200%–800% more on the “African” slope) caused the development of two distinct biomes. The south-facing slope is sunnier and has xeric, savannoid “African” environment while the north-facing slope is represented by temperate, “European” forested environment. Here we studied the phenotypic response of the S. cerevisiae strains to UVA and UVC radiations and to methyl methanesulfonate (MMS) in order to evaluate the interslope effect on the strains'' ability to withstand DNA-damaging agents.

Methodology/Principal Findings

We exposed our strains to the different DNA-damaging agents and measured survival by counting colony forming units. The strains from the “African” slope were more resilient to both UVA and MMS than the strains from the “European” slope. In contrast, we found that there was almost no difference between strains (with similar ploidy) from the opposite slopes, in their sensitivity to UVC radiation. These results suggest that the “African” strains are more adapted to higher solar radiation than the “European” strains. We also found that the tetraploids strains were more tolerant to all DNA-damaging agents than their neighboring diploid strains, which suggest that high ploidy level might be a mechanism of adaptation to high solar radiation.

Conclusions/Significance

Our results and the results of parallel studies with several other organisms, suggest that natural selection appears to select, at a microscale, for adaptive complexes that can tolerate the higher UV radiation on the “African” slope.     

Patients' accounts of being removed from their general practitioner's list: qualitative study

Objective To explore patients'' accounts of being removed from a general practitioner''s list.Design Qualitative analysis of semistructured interviews.Setting Patients'' homes in Leicestershire.Participants 28 patients who had recently been removed from a general practitioner''s list.Results The removed patients gave an account of themselves as having genuine illnesses needing medical care. In putting their case that their removal was unjustified, patients were concerned to show that they were “good” patients who complied with the rules that they understood to govern the doctor-patient relationship: they tried to cope with their illness and follow medical advice, used general practice services “appropriately,” were uncomplaining, and were polite with doctors. Removed patients also used their accounts to characterise the removing general practitioner as one who broke the lay rules of the doctor-patient relationship. These “bad” general practitioners were rude, impersonal, uncaring, and clinically incompetent and lied to patients. Patients felt very threatened by being removed from their general practitioner''s list; they experienced removal as an attack on their right to be an NHS patient, as deeply distressing, and as stigmatising.Conclusions Removal is an overwhelmingly negative and distressing experience for patients. Many of the problems encountered by removed patients may be remediable through general practices having an explicit policy on removal and procedures in place to help with “difficult” patients.