Delayed-type Necrosis after Soft-tissue Augmentation with Hyaluronic Acid

The growing use of dermal fillers, specifically the use of hyaluronic acid, can be explained by their effectiveness and versatility as well as their favorable safety profiles. Nevertheless, early and late complications with varying levels of severity may occur. The incidence of complications is low and the majority of adverse events are mild (edema, erythema, and local ecchymosis) and of limited duration. However, more severe events, such as ischemia and necrosis, may occur. The symptoms of ischemia can occur immediately after the injection or several hours after the procedure. Here, the authors report three cases of necrosis after hyaluronic acid injection with the first symptoms presenting only several hours after the procedure. The patients were treated immediately after the diagnosis. The aim of this review is to communicate the possibility of the delayed-type presentation of necrosis, present the signs and symptoms that lead to early diagnosis, and review the treatment possibilities of this severe complication.Dermal fillers have been injected with increasing frequency over the past three decades for soft-tissue augmentation by volume expansion in the management of the aging face. In 2012, there were about two million procedures using dermal fillers, according to the American Society of Plastic Surgeons, five percent more than in 2011 and 205 percent more than in 2000, second only to botulinum toxin type A. These minimally invasive and nonsurgical cosmetic procedures were the two most commonly performed in this range of time studied.1,2The growing use of dermal fillers, specifically the use of hyaluronic acid (HA), can be explained by their effectiveness and versatility as well as their favorable safety profiles. Nevertheless, early and late complications with varying levels of severity may occur. The incidence of complications is low and the majority of adverse events are mild (edema, erythema, and local ecchymosis) and of limited duration. However, more severe events, such as ischemia and necrosis, may occur.Injection necrosis is a rare, but important, complication associated with dermal fillers. Necrosis can be attributed to one of two factors—an interruption of vascular supply due to compression or frank obstruction of vessels by direct injection of the material into a vessel itself. The glabella is the injection site commonly believed to be at greater risk for necrosis, but it can also occur at the nasolabial fold.3 Risk factors for intravascular injection include site of application (deep injection of filler products at or near the site of named vessels), volume applied (larger amounts of product can cause a proportionally greater degree of arterial obstruction), and previous scarring (deep tissue scars may stabilize and fix arteries in place, making them easier to penetrate with small sharp needles).4The initial presentation of vascular events may include pain and discomfort disproportionate to what is typically experienced following filler treatments and clinical findings, including blanching, livedo pattern, or violaceous discoloration.4 Although many cases report this immediate post-injection presentation as the typical background seen in a necrosis event, there are few reports with the first symptom presenting only hours after augmentation. See Figures 1 through ​through3,3, where the authors present three cases of vascular compromise after soft-tissue augmentation with delayed-type presentation. Open in a separate windowOpen in a separate windowFigures 2Aand 2B.Case 2: Necrosis and secondary infection 48 hours after the HA injection (a). Discrete scars in the affected area after treatment (b). Open in a separate windowOpen in a separate windowFigures 1Aand 1B.Case 1: Edema, erythema, and progressive violaceous reticulated patch, livedoid area were observed on the left cheek 36 hours after the injection (a). Complete healing five days after hyaluronidase application and nine days after the HA injection (b). Open in a separate windowOpen in a separate windowFigures 3Aand 3B.Case 3: Necrosis and secondary infection 48 hours after the HA injection (a). Erythema, hipercromia, and discreet scars in the affected area after treatment (b).     

Folgen der Pneumonektomie in der Früh- und Spätphase

Pneumonectomy can represent the appropriate surgical treatment option in advanced or centrally localized non-small cell lung cancer (NSCLC). A satisfactory oncologic tumor surgery can be reached in these cases although pneumonectomy is associated with a significantly higher mortality and morbidity than less extensive resection of the lung parenchyma. The aim of this article is a systematic review and the presentation of possible postoperative consequences of pneumonectomy in the early and late phases, which depend not only on the underlying disease but are also primarily affected by the state and function of the remaining contralateral lung parenchyma. Cardiopulmonary complications, especially pneumonia, pulmonary embolism, cardiac arrhythmia or myocardial infarction lead to increased 30-day mortality in the early postoperative period. Moreover, advanced ages over 70 years can be identified as a significant risk factor for poor quality of life after pneumonectomy.     

Wound infection,dressings and pain,is there a relationship in the chronic wound?

The focus on quality of life issues in wound care has justly taken a far greater importance. With the acceptance that pain can be a major factor to the patient, and in particular, pain at dressing change comes the opportunity for avoidance and/or reduction strategies. Whilst pain has been associated with wound infection for millennia, it is only much more recently that this has received due attention from research and clinical practice. In this study, the nature of pain, changes in pain and pain associated with infection are the focal points. A Delphi approach, now a frequently used tool in wound care research, has been used to obtain expert opinion on these aspects of management.     

HAROW: the first comprehensive prospective observational study comparing treatment options in localized prostate cancer

Purpose

To collect data on primary treatment decision and follow-up in patients with diagnosed, histologically confirmed localized (T1a–T2c/N0/M0) prostate cancer (PCa) for up to 5 years in a prospective observational non-interventional study.

Methods

Patients were non-randomly allocated to one of the five treatment strategies: hormone therapy, active surveillance, radiation, operation, or watchful waiting.

Results

A total of 3169 patients were included by 259 participating sites; 2957 patients had at least one follow-up visit. 54.8 % of tumors at baseline were staged as T1c, 38 % as T2a–T2c, and 7.1 % as T1a or T1b (missing: 0.2 %). 38.9, 32.6 and 26.6 % of patients were classified as low risk, intermediate risk, and high risk according to d’Amico, respectively (missing: 1.8 %). 56.6 % of patients underwent prostatectomy as primary therapy, 16.4 % received radiation, 6.9 % HT, 15.8 and 4.3 % decided for AS or WW. Mean follow-up was 28.4 months. Progression rates were between 8.6 % (RT) and 33.1 % (AS).

Conclusion

Whereas RP remains the main treatment option of localized PCa, active surveillance appears to become an accepted and selectively employed treatment option. Careful selection of patients is documented by the highest proportion of patients with low risk (82.5 %), PSA density <0.2 ng/ml/ml (77.5 %), T1 staging (83.6 %), Gleason score ≤6 (92.5 %), ≤2 positive biopsies (79.4 %), and lowest mean PSA (5.8 ng/ml) in the AS group. The relatively high progression rate in the AS group has to be considered in the context of treatment changes; 71/155 patients had a documented change of treatment and 62 of them with a follow-up period of >3 months.

     

Der Stellenwert von Muttermilch für die gesunde Entwicklung Frühgeborener – aktuelle Übersicht und praktische Aspekte

Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz - In den letzten Jahren konnte der immense Vorteil der Muttermilchernährung für Frühgeborene belegt werden: in Bezug...     

Langzeitergebnisse nach operativer Rekonstruktion hoher Hüftluxationen bei infantiler Zerebralparese

Background

Hip dislocation as a result of neurogenic hip displacement is a common focal motor symptom in children with infantile cerebral palsy (ICP). In addition to contracture of the hip joint, in up to 65 % of cases patients suffer from pain which leads to further loss of function and often to limitations in important basic functions, such as lying, care, sitting, standing and transfer.

Methods

In order to avoid hip dislocation and to be able to implement therapy at an early stage, screening programs have been developed in recent years which clearly demonstrate the risks of hip displacement in ICP depending on the ability to walk. An investigation of the natural course is practically impossible because as a rule patients with painful neurogenic hip displacement receive surgical therapy.

Patients

In this study 96 patients with high hip dislocation grade IV on the Tönnis classification were included and 68 could be followed up. The average age at the time of surgery was 10.9 years and the mean follow-up period was 7.7 years. In the postoperative course 6 out of 91 reconstructed hips became redislocated and a proximal femoral resection was carried out in one female patient. The migration index according to Reimers was 14.0 % at the time of the follow-up examination.

Conclusion

Revision procedures can be avoided by screening programs. These should be strived for so that the neuro-orthopedic treatment on operation planning is not first initiated when pain occurs and revision procedures, such as angulation osteotomy or proximal femoral resection can be avoided. The reconstruction should also involve minimal deformation of the femoral head. In order to implement this, the interdisciplinary cooperation between neuropediatricians, social pediatriatricians and neuro-orthopedists should be intensified in the future.     

Cardiovascular Morbidity Associated with Gonadotropin Releasing Hormone Agonists and an Antagonist

Background

Androgen deprivation therapy (ADT) is associated with increased cardiovascular morbidity.

Objective

To determine whether cardiovascular morbidity differs following initiation of gonadotropin-releasing hormone (GnRH) agonists compared with an antagonist.

Design, setting, and participants

Pooled data from six phase 3 prospective randomized trials that recruited 2328 men between 2005 and 2012 to compare the efficacy of GnRH agonists against an antagonist. Men recruited had pathologically confirmed prostate cancer, an Eastern Cooperative Oncology Group score <2, a minimum life expectancy of 12 mo, and were naïve to ADT. Men were excluded if they had a prolonged baseline QT/corrected QT interval, other risk factors for heart failure, hypokalemia or a family history of long QT syndrome, or had another cancer diagnosed within 5 yr.

Intervention

Men were randomized to receive a GnRH agonist or an antagonist for either 3–7 mo (n = 642) or 12 mo (n = 1686). Treatment groups were balanced for common baseline characteristics.

Outcome measurements and statistical analysis

Event analysis was based on death from any cause or cardiac events. Data documenting adverse experiences were classified based on the Medical Dictionary for Regulatory Activities. The following conditions defined a cardiac event: arterial embolic or thrombotic events, hemorrhagic or ischemic cerebrovascular conditions, myocardial infarction, and other ischemic heart disease. Kaplan-Meier curves and log-rank tests were used to compare time to a cardiovascular event or death.

Results and limitations

Among men with preexisting cardiovascular disease, the risk of cardiac events within 1 yr of initiating therapy was significantly lower among men treated with a GnRH antagonist compared with GnRH agonists (hazard ratio: 0.44; 95% confidence interval, 0.26–0.74; p = 0.002). Since our analysis is post hoc, our findings should only be interpreted as hypothesis generating.

Conclusions

GnRH antagonists appear to halve the number of cardiac events experienced by men with preexisting cardiovascular disease during the first year of ADT when compared to GnRH agonists.