Biomedical subjects
Publications and source records attributed to C W Lober.
Skin changes caused by the natural aging process (intrinsic aging), as opposed to environmental assault (extrinsic aging), are now recognized and delineated. These alterations play a role in the etiopathogenesis of many of the skin problems that develop in elderly patients. Structural and functional changes that occur in normal aging skin are discussed with respect to their relationship to common skin disorders in the elderly.
We have reviewed the issue of physician drug dispensing by focusing upon quality of care, economic considerations, drug availability, patient compliance, safety, and increased governmental regulation. From a quality of care perspective, the increased use of pharmacist assistants, the tendency toward generic and therapeutic drug substitution, and the less specialized clinical education of pharmacists all pose hazards rather than safety checks upon physician prescribing. There is no evidence that pharmacists charge less than physicians. If they did, there would be no need to protect their incomes legislatively by restricting physician dispensing. Economic motivation per se is less important to a physician than providing a true convenience for his patients and thus encouraging a closer doctor-patient relationship. Physician dispensing adds to the availability of medication and may minimize the number of patients shuttling between pharmacies to obtain complex multi-ingredient preparations. Compliance is enhanced as availability increases. Prepackaged pharmaceuticals prepared under the auspices of pharmacists and dispensed by physicians are at least as safe as those prepared by the ungloved hands of a pharmacist hidden behind store counters. Thus, restricting the physician's right to dispense can negatively affect the quality of medical care, the cost of medications, safety, the availability of pharmaceuticals, and patient compliance. Such limitation is certainly not in the best interest of our patients.
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Chemexfoliation (chemical peeling) is being used to obtain both therapeutic (e.g., actinic keratoses) and cosmetic (e.g., removal of fine facial rhytides) benefits. Phenol, one of the most widely used agents for inducing cutaneous exfoliation, may induce cardiac arrhythmias and is toxic to the liver and kidneys. Trichloroacetic acid is not significantly absorbed and therefore does not produce systemic complications. Both phenol and trichloroacetic acid may produce hypertrophic scars and/or keloids and pigmentation irregularities, may accentuate preexisting abnormalities (e.g., telangiectasias, nevi, and pores), and may be associated with a flare of latent herpesvirus infection. Prolonged erythema of the treated areas and persistent rhytids have been reported with both agents.
The rationale for our current day use of absorbable and nonabsorbable suture materials is based upon the biology of wound healing and the physiologic response of tissue to implanted sutures. An understanding of the fundamental characteristics of suture materials and surgical needles is necessary if one is to obtain optimal surgical results.
Solar-induced cutaneous changes are more prevalent and profound in older persons and, thus, are often inappropriately attributed to the aging process, per se. Structural and functional alterations caused by intrinsic aging and independent of environmental insults are now recognized in the skin of elderly individuals. Structurally the aged epidermis likely becomes thinner, the corneocytes become less adherent to one another, and there is flattening of the dermoepidermal interface. The number of melanocytes and Langerhans cells is decreased. The dermis becomes atrophic and it is relatively acellular and avascular. Dermal collagen, elastin, and glycosaminoglycans are altered. The subcutaneous tissue is diminished in some areas, especially the face, shins, hands, and feet, while in others, particularly the abdomen in men and the thighs in women, it is increased. The number of eccrine glands is reduced and both the eccrine and apocrine glands undergo attenuation. Sebaceous glands tend to increase in size but paradoxically their secretory output is lessened. The nail plate is generally thinned, the surface ridged and lusterless, and the lunula decreased in size. There is a progressive reduction in the density of hair follicles per unit area on the face and scalp, independent of male-pattern alopecia. The hair shaft diameter is generally reduced but in some areas, especially the ears, nose, and eyebrows of men and the upper lip and chin in women, it is increased as vellus hairs convert to cosmetically compromising terminal hairs. Functional alterations noted in the skin of elderly persons include a decreased growth rate of the epidermis, hair, and nails, delayed wound healing, reduced dermal clearance of fluids and foreign materials, and compromised vascular responsiveness. Eccrine and apocrine secretions are diminished. The cutaneous immune and inflammatory responses are impaired, particularly cell-mediated immunity. Clinical correlates of these intrinsic aging changes of the skin include alopecia, pallor, xerosis, an increased number of benign and malignant epidermal neoplasms, increased susceptibility to blister formation, predisposition to injury of the dermis and underlying tissues, delayed onset and resolution of blisters and wheals, persistent contact dermatitis, impaired tanning response to ultraviolet light, increased risk for wound infections, prolongation of therapy necessary for onychomycosis, and thermoregulatory disturbances.
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The limitations of the Limberg, Dufourmentel, and Webster flaps are analyzed. The use of multiple rhomboidal transposition flaps to close rhomboidal surgical defects is illustrated.
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A 24-year-old man developed a papular eruption on his hands after butchering sheep. Viral cultures and serum antibody levels confirmed the diagnosis of orf. The clinical features, histologic findings, and diagnostic criteria of orf are described.
Heat-killed sonicated suspensions of malassezia ovalis and Staphylococcus epidermidis were applied to the intact volar surface of the forearm of ten patients with psoriasis and ten control subjects. All ten of the patients with psoriasis reacted to M ovalis, and four patients reacted to S epidermidis. Two of the control subjects responded to M ovalis, and none responded to S epidermidis. Lesions that both clinically and histologically were consistent with those of psoriasis developed in the patients with psoriasis.
Twenty-eight patients with severe cutaneous infections received cefoperazone, 2 grams intramuscularly twice a day for seven days. A wide range of gram-positive and gram-negative pathogens were isolated from admission cultures. All patients showed rapid clinical improvement. Two patients did not complete the full course of therapy because of intervening medical problems unrelated to the antibiotic. No significant side effects were noted. Relapses or reinfections occurred in two patients. In conclusions, cefoperazone is a safe and effective antibiotic for use in skin infections requiring parenteral therapy.
A 34-year-old woman had a granulomatous ulceration of the nose that responded to radiation therapy. The limitation of the disease to the nose and the histologic findings were consistent with a diagnosis of midline granuloma, Stewart type. The relationship of midline granuloma to Wegener's granulomatosis is reviewed. In view of the uniform mortality that accompanies untreated midline granuloma, a correct diagnosis must be made so that radiation therapy can be promptly instituted.
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