Management of Infected Implantable Cardiac Defibrillators

Background. The implantable cardiac defibrillator (ICD) was introduced clinically in 1980 for the management of ventricular arrhythmias.

Methods. From January 31, 1989, through May 29, 1996, 329 ICD devices were implanted at Allegheny University Hospital, Hahnemann Division, Philadelphia, Pennsylvania. All device-related infections were examined.

Results. Fifteen patients (5%) experienced infection of the generator component of the ICD. There were 14 male and 1 female patients with a mean age of 62 years (range, 38 to 79 years). All infections involved the generator with or without other component involvement. Complete removal of the system was performed in 7 patients, partial removal in 5, and the entire system was left intact in 3. In 4 patients (27%), further procedures were performed to remove additional infection. Three patients (20%) died during the hospital stay.

Conclusions. Infection of ICD devices is a devastating event. We favor complete removal of the ICD generator and all the components when possible. Partial removal of the ICD unit (ie, generator only) is reserved for patients in whom the risk of complete removal is too high and infection is confined to the generator only.     

Authors in Dermatologic Surgery

Authors of scientific papers have been evaluated in the past by how frequently the medical literature cites them. In this analysis, we specifically identify those individuals who have contributed to the field of cutaneous surgery through publications in Dermatologic Surgery. We further analyze those publications frequently cited in Dermatologic Surgery, allowing us to determine topics of utmost value and interest. Using a citation database provided by the Institute for Scientific Information, we first identify all publications and citations from 1981 to 1999 for Dermatologic Surgery and the Journal of Dermatologic Surgery and Oncology (the previous name for this journal). Of the original articles published during this time frame, 3099 authors published 2167 papers. We quantify the publications from each author, and identify 57 authors with at least 10 original articles. When expanding the database parameters to include original articles, reviews, notes, and proceedings (as defined by the Science Citation Index), we find that the eight authors with the greatest number of publications are the same individuals with the greatest number of original articles. This reflects significant contributions to the field of cutaneous surgery by these authors. This analysis further identifies source papers for authors in Dermatologic Surgery. Publications frequently cited include those papers discussing laser surgery, with Dermatologic Surgery serving as the most frequently cited journal.     

Dermatologic Surgery Training in Residency

BACKGROUND: Dermatologic surgery is an integral part of dermatology residency training. OBJECTIVE: To characterize the current level of surgical training in dermatology residency programs. METHODS: A survey was mailed to the 112 dermatology residency programs in North America and Puerto Rico. RESULTS: A total of 71 residency programs (63%) responded. All programs offer training in surgical excisions, 97% of programs train residents in at least one cosmetic procedure, 92% of programs offer Mohs micrographic surgery, and 90% of programs train their residents in laser surgery. CONCLUSION: Surgical training in dermatology residency varies widely, with a trend toward more cosmetic procedures when compared with prior studies.     

Implantable Cardioverter Defibrillators: Current Status and Future Directions

Sudden cardiac death remains the most common mode of mortality in the United States, accounting for up to 450,000 deaths per year. Survivors of cardiac arrest and patients who have recurrent ventricular tachycardia have a high mortality rate with or without antiarrhythmic therapy. The implantable cardioverter defibrillator (ICD) was introduced in 1980 by Mirowski as a potential treatment for these patients. There are presently over 24,000 implants worldwide and the device has proved to be an effective means of preventing sudden death. The components of an ICD include a generator, defibrillation patches or leads, and pacing/sensing leads. The devices can be implanted with acceptable mortality and morbidity either by median sternotomy, left anterior thoracotomy, subxiphoid, or left subcostal approaches. The long-term results have been excellent with an actuarial incidence of sudden cardiac death of 3% at 5 years. Improvements in battery and capacitor technology, lead design, and tachycardia recognition, combined with the addition of hemodynamic sensors and a better understanding of the science of defibrillation, should lead to further improvements over the next several years in the ICD.     

Informed Consent in Dermatologic Surgery

BACKGROUND: The issue of informed consent retention has not been previously addressed in dermatology literature. Several studies in other fields of medicine have shown that retention rates are below 50%. OBJECTIVE: To determine the percentage of complications recalled at 20 minutes and at 1 week after the informed consent process. METHODS: Eighty-five consecutive patients undergoing Mohs micrographic surgery were given verbal and written instructions, including 10 potential complications. Patients were asked to recall these complications at 20 minutes and at 1 week after the informed consent process. RESULTS: Overall group retention rate at 20 minutes and at 1 week were 26.5% and 24.4%, respectively. CONCLUSION: Patients undergoing elective Mohs micrographic surgery have an overall retention rate of 26.5% just 20 minutes after being informed of 10 possible complications. It is obvious that the informed consent protocol needs additional modalities in order to improve overall retention rates.     

Cardiac Devices and Electromagnetic Interference Revisited: New Radiofrequency Technologies and Implications for Dermatologic Surgery

Background and Objective. As the number of patients with implantable cardiac devices escalates, inadvertent electromagnetic interference (EMI) by electrosurgery carries increasing concern for patient safety. Given the trend for dermatologic care delivery by nonphysician providers, supervising physicians must carefully consider the adequacy of perioperative evaluation in elective or cosmetic settings. Rapidly evolving technology also calls into question potential EMI of new therapeutic modalities (radiofrequency resurfacing, electrochemotherapy, and endovenous ablation). The most recently published recommendations (1998) for care of dermatologic patients with cardiac devices do not differ significantly from guidelines proposed in 1975. These recommendations, based on complications experienced during noncutaneous surgery, are exceedingly conservative and do not take into consideration the different electrosurgical modalities and varying degrees of EMI risk. In addition, modern cardiac devices have evolved significantly with increased sophistication in protection from EMI. A survey of dermatologic surgeons demonstrated low compliance with these existing guidelines.
Methods, Results, and Conclusions. Based on a review of the literature and current electrosurgical and cardiac devices, we discuss the potential impact of conventional dermatologic electrosurgery and new technologies. We propose that new perioperative guidelines are needed to provide appropriate safety, facile implementation, and cost-effective care for patients with modern implantable cardiac devices.     

Porcine Heterografts in Dermatologic Surgery and Reconstruction

BACKGROUND: Porcine heterografting is a method that can be used to reestablish the protective integrity of skin after cutaneous injury. These grafts may be used in an assortment of clinical situations for chronic and acute wounds, burn injury, and partial- or full-thickness areas of skin loss. OBJECTIVE: The purpose of this article is to address the indications for using porcine heterografts in dermatologic surgery, the advantages and disadvantages of their use, and the technique of graft application. METHODS: Indications for porcine heterografts and the methodology of graft application are discussed. RESULTS: Porcine heterografts serve as a valuable tool in a variety of reconstruction settings in dermatologic surgery. CONCLUSIONS: Heterografts provide an inexpensive method to facilitate wound care and promote healing, and serve as an effective repair option for a variety of surgical defects.     

Current Issues in Dermatologic Office-Based Surgery

Dermatologists and dermatologic surgeons have played major roles in the development and refinement of many office-based cutaneous surgical procedures. The comprehensive scientific education in the structure and function of skin that dermatologists receive during formal residency training programs has contributed directly to these advances. This long tradition of comprehensive training and strong basic research activities in skin biology has supported a scholarly approach to cutaneous surgery. As a result, many pioneering cutaneous surgical techniques have been created by dermatologists and dermatologic surgeons. One example of this creativity can be seen in the field of laser surgery where techniques to effectively treat tattoos, benign pigmented lesions, port-wine stains and other vascular conditions, premalignant and malignant skin lesions, wrinkles and sun-damaged skin, and excess or unwanted hair were developed by dermatologists. Some of the most innovative procedures, like tumescent liposuction, have focused primarily on improving patient safety while preserving the highest standards of care. Virtually every aspect of cutaneous surgery, including Mohs micrographic surgery for the treatment of skin cancers, hair replacement surgery, sclerotherapy of leg veins, the correction of scars and sun-damaged skin with the injection of filler materials, dermabrasion or chemical peels, and new anesthesia techniques, have been favorably impacted by the unique education and skills of many dermatologists and dermatologic surgeons. This article reviews the important historic role that has been played by dermatologists and dermatologic surgeons in developing and improving outpatient cutaneous surgical procedures and examines current issues and future directions in credentialing, privileging, and accreditation.     

Inherited Bleeding Disorders in Dermatologic Surgery

BACKGROUND: A patient referred for Mohs micrographic surgery of a basal cell carcinoma had a history of a congenital clotting factor IX deficiency requiring recombinant factor IX replacement. OBJECTIVE: To examine the management and problems associated with cutaneous surgery in patients with inherited clotting factor deficiencies. METHODS: Case report and review of the medical literature. RESULTS: Reconstructive options must be carefully chosen to minimize bleeding in patients with clotting factor deficiencies. Preoperative consultation with a hematologist and coagulation factor replacement both before and after cutaneous surgery prevent excessive hemorrhage. CONCLUSION: Meticulous attention to hemostasis, careful preoperative assessment, and postoperative follow-up minimize complications in patients with known coagulation deficiencies who require cutaneous surgery.     

Dermatologic Surgery in the Demented Patient

BACKGROUND: Dementia is an organic mental disorder that is characterized by a general loss of intellectual abilities involving impairment of memory, judgment, and abstract thinking as well as changes in personality. Demented patients are a growing subgroup within the practice of dermatologic surgery and especially in Mohs surgery. These patients often have other medical and social concerns in addition to their dementia. OBJECTIVE: Demented patients require specific knowledge of their problems to care for them properly, especially in cases in which prolonged procedures are required such as Mohs surgery. METHODS: A review the literature is given regarding this subgroup of patients and how to best prepare and care for them before, during, and after dermatologic surgery. RESULTS: Demented patients often have other medical concerns and therefore have associated medications, medical ailments, postsurgical care, and social and mental challenges. CONCLUSION: The dermatologic surgeon needs to be aware of the special concerns of demented patients, especially in prolonged and potentially complicated surgeries. Not only do they have mental challenges, but they often have other medical and social challenges that need to be specifically accounted for before, during, and after dermatologic surgery.     

Glove Perforation in Outpatient Dermatologic Surgery

BACKGROUND: Intact surgical gloves ensure protection of health-care employees and health-care recipients. Nevertheless, glove perforation is very common and puncture rates above 50% have been published in the literature. OBJECTIVE: It was our aim to evaluate the perforation rate of surgical gloves in outpatient dermatologic surgery. METHODS: Six-hundred and sixty latex surgical gloves used in outpatient dermatologic surgery were evaluated for perforations using the approved water-leak method. Perforations were analyzed microscopically. RESULTS: Twenty of the 660 gloves were found to have perforations, which corresponds to a perforation rate of 3.0%. Only 5 of these perforations (25%) were noticed by the wearer. Perforations were more numerous in nondominant-handed gloves. Microscopically, all perforations could be identified as needle stick injuries. CONCLUSION: The risk of glove perforation in outpatient dermatologic surgery is lower than in many other medical specialties. The relatively high number of surgical procedures performed successively in outpatient dermatologic surgery, however, emphasizes the decisive relevance of an intact barrier between surgeon and patient. In view of the major fact that most perforations go unnoticed by the wearer, dermatologic surgeons must balance the improved safety of double gloving with costs and the loss of sensitivity and dexterity.     

Application of Local Anesthetics in Dermatologic Surgery

BACKGROUND: Local anesthesia is an integral aspect of cutaneous surgery. Its effects provide a reversible loss of sensation in a limited area of skin, allowing dermatologists to perform diagnostic and therapeutic procedures safely, with minimal discomfort and risk to the patient. OBJECTIVE: This article discusses the application of local anesthetics in dermatologic surgery through a brief review of the mechanism of local anesthetic activity, classification of local anesthetics, and adverse effects. The discussion will focus on the different methods of administration and techniques that may make the administration less painful to patients. METHODS: An evaluation of the literature, as well as clinical experience in the administration of local anesthetics provide the basis for this review. CONCLUSION: Local anesthesia provides a safe and effective means of decreasing patient's sensitivity to pain. Because of its critical importance to the field of dermatology, a working knowledge of local anesthetics is necessary for optimal use of these agents.