1/15. Stigmata: part I. shame, guilt, and anger.The aesthetic surgeon may occasionally be consulted by a patient who wishes to discuss what can be done for the scars of self-inflicted wounds on the forearms. These scars are popularly referred to as "hesitation marks" or "suicide gestures." Unlike patients suffering from factitial ulcers or Munchhausen syndrome, these patients will admit to the physician that the scars are the result of self-inflicted wounds. These scars often consist of multiple, parallel, white lines extending up and down the forearms (usually volar surface), with more on the nondominant side. Although the pattern of these scars is apparently what drives these patients to the aesthetic surgeon for relief (because even lay people identify these scars as self-inflicted suicide marks), the authors propose a new and deeper motivation for surgery. Recent experiences with three of these patients resulted in an epiphany that prompted this report. Once the symbolic meaning of these scars was broached, a torrent of thoughts and theories followed. This article will recount these three cases and present a central thesis for this type of self-inflicted injury. A proposal for the proper surgical treatment of this condition will be offered. Uniquely, two of the patients will relate their own stories and propose guidelines and warnings for the aesthetic surgeon.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/15. Linear IgA disease.PURPOSE: A case of linear IgA disease is reported to alert ophthalmologists and physicians to this unusual cause of chronic cicatrizing conjunctivitis. methods: Clinical records of a patient suffering from linear IgA disease were reviewed. RESULTS: A 65-year-old woman with a complicated medical history experienced rapidly progressive chronic cicatrizing conjunctivitis leading to corneal perforation. Undiagnosed gingivitis and palatal ulceration had been present for 5 years prior to the onset of ocular symptoms and vitamin C deficiency had followed the consequent dietary restrictions. A diagnosis of linear IgA disease was made on conjunctival biopsy, which demonstrated linear deposits of IgA along the epithelial basement membrane. The perforation was managed successfully with a conjunctival pediculate flap. Control of the inflammation was achieved with systemic prednisolone and cyclophosphamide but at the expense of serious systemic side-effects. CONCLUSIONS: Linear IgA disease causes progressive conjunctival cicatrization in many affected individuals.Although dapsone generally controls the inflammation, heavier systemic immunosuppression was required in this case. Involvement of skin or other mucosal surfaces may become symptomatic before the conjunctivitis, and physicians must be educated to refer patients for ophthalmological review on diagnosis. Conversely, ophthalmologists encountering ocular linear IgA disease should be aware of the possibility of other mucosal involvement requiring physician intervention.- - - - - - - - - - ranking = 3keywords = physician (Clic here for more details about this article) |
3/15. Malignant melanoma in a skin graft: burn scar neoplasm or a transferred melanoma?Malignant melanomas (MM) arising in burn scars are rare with 16 cases previously reported. Malignant melanomas arising on skin grafts are even more rare with only two cases reported. We present the case of MM arising on a burned area that had been previously grafted with a split thickness skin graft. A 19-year-old patient sustained 20% burns in a road traffic accident. The burned areas were debrided and skin grafted. Six months later, the patient developed MM on the left calf (an area that was burned and grafted). The tumour was excised with wide margins. Six months following the excision of the MM, the patient started to develop multiple dysplastic naevi in the skin grafted burned areas. In the present case, the main question to be answered is whether the MM arose from the donor or the recipient site of the split thickness skin graft. After thorough discussion of the two options and reviewing the literature, the authors believe that the MM and the atypical naevi were transferred to the recipient site with the skin graft. Therefore, it is suggested that in the process of harvesting skin grafts, any pre-existing naevi should be avoided or removed, and if this is not feasible, should be recorded in detail in the operation notes. Also, patients at discharge should be advised that any change in the appearance of the grafts or any new lesions in the engrafted areas should be reported to their physicians.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/15. Malignancy in chronic ulcers and scars of the leg (Marjolin's ulcer): a study of 21 patients.OBJECTIVE: To study the imaging features of patients with chronic ulcers of the leg that were associated with malignancy. DESIGN AND patients: All patients who on biopsy were proven to have malignancy--the majority of which were squamous cell carcinoma-were included in a prospective study. Ulcers limited to the foot were excluded but ulcers of the leg which extended into the foot were included. amputation was performed in all but two patients, due to pain, bleeding or tissue necrosis. RESULTS: The etiology was multifactorial. The mean duration of the ulcers was 36 years including venous ulcers, extensive scarring of the leg secondary to infection, injury or burns. One ulcer was secondary to a snake bite. The remainder, usually in the upper part of the leg, had repeated episodes of blunt trauma or knife wounds, which were also complicated by infections which failed to heal or, if they healed, regularly recurred. Although arterial insufficiency was not primary in any patient, most were of advanced age and it may have been an element in some patients. Despite infection, osteomyelitis was present in only one patient. The essential features were bone destruction, soft tissue mass and periosteal reaction. The bone destruction was visible on the radiographs in all but one case. The soft tissue masses varied in size but in general were very large. The periosteal reaction varied in type but most commonly was lamellated. The classic undulating solid periosteal reaction of venous stasis was only occasionally present. The periosteal reaction was nonspecific in the majority of cases and did not aid in the diagnosis or etiology. MRI and CT studies were performed in six patients. These were helpful in defining the extent of bone destruction and periosteal reaction but were not essential in management. CONCLUSION: Chronic ulcer present for decades that then undergoes malignant change is a disease of developing countries where patients only consult physicians when they have developed complications such as pain, bleeding or tissue necrosis. Chronic ulcers may require to be biopsied at regular intervals as malignant change in these ulcers is directly related to their duration.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/15. Chronic cicatrizing conjunctivitis in a patient with ocular cicatricial pemphigoid and fatal wegener granulomatosis.PURPOSE: To describe a case of chronic cicatrizing conjunctivitis in a patient with ocular cicatricial pemphigoid and wegener granulomatosis. methods: Observational case report. A retrospective study. RESULTS: An 80-year-old man presented with chronic cicatrizing conjunctivitis, peripheral corneal thinning, and wegener granulomatosis, which were diagnosed by his referring physician based on clinical (recurrent epistaxis, sinus congestion) and histopathologic features of nasal mucosa (granulomatous inflammation, vasculitis). A conjunctival biopsy performed by us disclosed features of active wegener granulomatosis and ocular cicatricial pemphigoid, which indicate lack of control of both diseases with methotrexate treatment. The patient died of pulmonary complications from Wegener granulomatosis 1 week after our evaluation. CONCLUSION: Ocular cicatricial pemphigoid and wegener granulomatosis are both potentially fatal autoimmune diseases. Ocular involvement in wegener granulomatosis indicates poor control of the underlying systemic condition and is a marker for active vasculitis, which indicates the need for treatment with cyclophosphamide.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/15. Botulinum toxin to minimize facial scarring.Botulinum toxin injection has been used for a variety of indications in humans, including blepharospasm and hyperfunctional facial lines. This article describes a novel formulation of botulinum toxin, which supplies immediate feedback to the injecting physician. Additionally, recent findings are described that indicate the immediate injection of botulinum toxin into the muscles underlying a wound can improve the cosmetic outcome of the facial cutaneous scar. Future applications of these findings are discussed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/15. Preservation of uterine integrity via transarterial embolization under postoperative massive vaginal bleeding due to cesarean scar pregnancy.OBJECTIVE: Cesarean scar pregnancy (CSP) is an uncommon type of ectopic pregnancy. It results in uterine rupture and severe hemorrhage during the proceeding gestation. Whether diagnosed early or not, it may cause maternal mortality or morbidity during emergency management. life-saving emergency hysterectomy is usually the treatment of choice when there is profuse bleeding intraoperatively or after initial management. CASE REPORT: A 38-year-old woman with a history of two previous cesarean deliveries was referred to our clinic under the impression of CSP at 11 weeks' gestation. A viable embryo with a crown-rump length of 4.8 cm in the anterior wall of the uterus at the cervico-isthmic region was detected. Under the confirmation of CSP via ultrasonography, she was admitted for management. During hysterotomy, profuse bleeding with 1,000 mL blood loss was noted. After conservative procedure for hemostasis, however, massive vaginal bleeding persisted. As a result, we immediately transferred the patient to receive transarterial embolization (TAE) for bleeding control. The patient was discharged 4 days after the operation and TAE and her period resumed 1 month later. CONCLUSION: Management of CSP is usually accompanied by profuse blood loss. hysterectomy is inevitable if massive blood loss occurs during surgical intervention. For preservation of fertility and avoidance of mortality, our physicians offered an alternative life-saving policy even under catastrophic blood loss.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/15. Constricting bands. Manifestations of possible child abuse. case reports and a review.Bands around extremities may be from congenital, infectious, accidental, or purposeful causes. The older child may reveal the cause of self-inflicted or caregiver-inflicted banding. Banding in a nonverbal child will challenge the diagnostic acumen of the physician. Bands of unknown cause, or bands that may have been placed purposefully by a caretaker, must be reported as possible child abuse. Failure of the caretaker to seek help for the consequences of a band may suggest that the bands were intentionally placed. This failure may also be construed as medical neglect. Four cases of banding, which were referred to a child abuse program for consultation, are described.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/15. An unusual cause of abdominal pain and shock in pregnancy: case report and review of the literature.A near fatal case of spontaneous uterine rupture resulting from placenta percreta is presented. placenta accreta refers to all conditions in which placental villi attach to, invade, or penetrate the myometrium. Placenta percreta is the most extreme form of morbid placental attachment and is said to exist when the uterine wall is completely breached by invading placental villi. Although uncommon, placenta percreta is an important entity of which the emergency physician should be aware because of its propensity to cause uterine rupture and catastrophic bleeding. This article reviews the pathophysiology, presentation, diagnosis, and emergency department management of placenta accreta, increta, and percreta.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/15. Treatment site reactions to Zyderm collagen Implantation.Two cases of treatment site granulomatous reaction to Zyderm collagen Implant that occurred in spite of a negative skin test are reported. A delayed hypersensitivity reaction to ZCI is suggested by the clinical time course and the histologic findings of hypersensitivity granulomas. Humoral immunity is also implicated in the reaction since elevated anti-Zyderm serum antibodies and plasma cell infiltrates are present. Resolution of the clinical signs and symptoms occurred over several months with no treatment. The physician using ZCI should be aware of this rare adverse reaction.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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