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Reactive fetal heart rate response to vibroacoustic stimulation in fetuses with low scalp blood pH.

Fetal vibroacoustic stimulation in fetuses with suspicious or ominous fetal heart rate traces in labour was followed by acid-base balance determination on fetal scalp blood within 30 min of the test. The mean fetal scalp blood pH values were significantly higher in fetuses that showed reactive responses with fetal heart rate acceleration compared with those who had no response or responded with a deceleration to the vibroacoustic stimulation (pH 7.30 and 7.22 respectively). However, acidotic scalp blood pH values (7.16 and 7.18) were found in two fetuses which had shown reactive responses both to vibroacoustic stimulation and pain stimuli with scalp blood sampling.

Acid-Base Equilibrium↗

Lactate compared with pH analysis at fetal scalp blood sampling: a prospective randomised study.

OBJECTIVE: Fetal scalp blood sampling is a widely used method for assessing fetal condition in the event of ominous fetal heart rate patterns. The purpose of this randomised trial was to compare the value of fetal scalp blood lactate and pH management in cases of abnormal intrapartum fetal heart rate tracings. METHODS: Of 341 cases of ominous fetal heart rate patterns, 169 were randomly assigned to pH analysis, and 172 to lactate measurements. Lactate was measured using a lactate card requiring 5 microL of blood and yielding the result within 60 seconds. pH analysis was performed with an ABL 510 acid-base analyser requiring 35 microL of blood and yielding the results within 47 seconds. RESULTS: Unsuccessful fetal blood sampling procedures (no result or an unreliable result) occurred significantly more often in the pH subgroup than in the lactate subgroup (OR 16.1 with 95% CI 5.8-44.7). In the pH subgroup the failure rate was inversely related to the degree of cervical dilatation. Compared with the pH subgroup, the lactate subgroup was characterised by fewer fetal scalp incisions per blood sampling attempt (median 1.0 [interquartile range (IQR) 1-1] vs 2.0 [IQR 1-2]), and significantly less time required for the sampling procedure (median 120 s [IQR 90-147] vs 230 s [IQR 180-300]). The groups did not differ in mode of delivery, neonatal outcome and umbilical artery acid-base balance and lactate levels. CONCLUSION: This trial showed the levels of lactate and pH in fetal scalp blood to be comparable in predicting perinatal outcome, but the procedure to measuring lactate was more successful than that for pH. Owing to its simplicity of performance, lactate analysis is an attractive alternative for intrapartum fetal monitoring.

Female↗

Advantages of the paramedian scalp reduction.

The paramedian scalp reduction as compared to the midline (sagittal) scalp reduction provides distinct advantages, particularly in the patient who has undergone reconstruction of the frontal hairline. The paramedian approach causes less distortion of the frontal hairline, allows greater direct visualization of the advancement flaps, permits more extensive undermining, creates less stretchback, provides for coronal advancement of the hair-bearing occipital donor site, and allows for a greater amount of camouflage of the scalp reduction scar during the immediate postoperative period. Surgeons should be knowledgeable and capable of providing varied forms of scalp reduction procedures to meet the specific needs of the various patients that present for hair replacement surgery.

Alopecia↗

Aids to scalp reduction surgery.

Utilizing certain surgical techniques during scalp reduction surgery will assist the surgeon in achieving a carefully planned and more efficient result. Measurement of scalp depth will assist in predicting the amount of skin to be excised. A simple method of safe identification of the periosteum is described along with the description of an elevator which assists in rapid, safe, and extensive undermining in the galeal-periosteal plane. An accessory supra-auricular scalp incision can be employed to allow for extensive scalp undermining. A transverse incision into the skin flap to be advanced, allows the surgeon to safely approximate the amount of skin to be excised. When skin closure becomes impossible due to overzealous excision of bald skin, galeotomies can provide closure. A special order suture is described which allows for easier galeal closure. Surgical skin staples are recommended to provide a faster skin closure.

Alopecia↗

Adjuncts to scalp reduction surgery. Intraoperative tissue expanders and hyaluronidase.

Scalp reduction has become an important part of the cosmetic surgeon's armamentarium in the treatment of male pattern alopecia. Recently, the use of two-stage tissue expansion has been advocated for scalp reduction. Intraoperative tissue expansion obviates many of the disadvantages of delayed expansion and increases the yield of excised scalp by 20-30% over standard reduction techniques in the 20 patients studied. The addition of hyaluronidase to the local anesthetic facilitates its diffusion, enhancing anesthesia and the ease of dissection. Therefore, the use of intraoperative tissue expansion and the addition of hyaluronidase to the local anesthetic are two separate adjuncts to scalp reduction surgery.

Alopecia↗

The effectiveness of occipital artery ligations as a priming procedure for extensive scalp-lifting.

Extensive scalp-lifting is a relatively new cosmetic scalp procedure that involves cutting both occipital arteries, which then allows undermining of the entire donor dominant scalp down to the hairline of the nape. Because of this more extensive undermining, dramatic improvements are accomplished even with one operation. Conversely, one can develop necrosis at the nuchal ridge because of a sudden curtailment of circulation in the occipital region. In an attempt to eliminate this complication, the author experimented with "horizontal incision ligations" of the occipital arteries 4 to 8 weeks prior to the surgery which resulted in a significant reduction in the average size of necrosis (from 3.1 cm2 to 1.6 cm2; P = .036) but no significant difference in the incidence (P = .49). When these patients did develop necrosis, it always occurred below the horizontal incisions--therefore, the procedure was changed to vertical incisions, which to date have yielded a significant protective effect when compared with the previous method of "horizontal incision ligations" (P = .014), and even greater significance when compared with the original method of no previous ligations (P = .012). Vertical-incision ligation performed 4 to 8 weeks prior to surgery is an optimal method for preventing the complication of necrosis after extensive scalp-lifting surgery.

Adult↗

Extensive scalp lifting. Decrease in complications utilizing unilateral occipital artery ligation and other modifications.

The superior yield from extensive scalp lifting has been detracted from by complications, including hemorrhage, scalp necrosis, and the need for greater anesthesia. Intraoperative unilateral occipital artery ligation, with extensive undermining to the nape of the neck on only one side, can minimize the risk of postoperative scalp necrosis or telogen effluvium. Careful hemostasis, extensive infusion of dilute anesthetic, and modifications in instrumentation can decrease the morbidity associated with this procedure. The advantages of the operation include removal of the large amounts of bald scalp, excellent intraoperative visualization, and lack of stretchback and asymmetry.

Alopecia↗

Scalp lifting. An 8-year experience with over 1,230 cases.

BACKGROUND: This article reviews the author's 8-year experience with extensive scalp-lifting, which includes 1,230 cases. OBJECTIVE: To overview extensive scalp-lifting paying particular attention to the areas of complications and the ways to reduce them. METHOD: Retrospective analysis of 1,230 cases was done. Necrosis, infection, hematoma, numbness, and scarring were evaluated. RESULTS: 1) Vertical incision occipital artery ligatory should be performed 4 to 8 weeks prior to a scalp lift. 2) Use a delay procedure prior to a frontoparietal advancement flap. 3) Use only lateral lifts on patients with prior punch-grafting. 4) Locate the temporal arteries preoperatively with Doppler ultrasonography. 5) Do not perform frontoparietal advancement flaps on patients with prior punch-grafts. CONCLUSION: Scalp lifting is an extremely effective and expedient method to treat alopecia; however, certain precautionary measures must be taken to obtain excellent, consistent results.

Alopecia↗

Scalp EMG in brain death electroencephalogram.

Electromyograms (EMGs) are usually considered artifacts during electroencephalographic (EEG) recording for determination of electrocerebral silence (ECS). Appearance of scalp motor unit activity, however, may reflect residual brainstem function and can introduce difficulty in establishing a secure diagnosis of brain death. In this study, ECS patients with and without scalp EMG were compared in terms of relationship to brainstem survivability. There was no correlation between length of survivability and presence of scalp EMG activity. No patient recovered brainstem function clinically. This study provides firm support for the usual practice of ignoring the EMG in brain death EEG. Scalp has no prognostic value.

Adolescent↗

Expression of nerve growth factor and its high-affinity receptor, tyrosine kinase A proteins, in the human scalp skin.

BACKGROUND: Nerve growth factor (NGF) and its high-affinity receptor, tyrosine kinase A (TrkA), are members of the neurotrophin family. NGF-TrkA are involved in murine hair morphogenesis and cycling. To date, their expression in human hair follicle (HF) is unknown. In this investigation, we hypothesize that NGF-TrkA proteins are expressed in the human scalp skin. Moreover, NGF-TrkA expression in HF changes with the transitions from anagen-->>catagen-->>telogen stages. MATERIALS AND METHODS: To test our hypothesis and to fill this existing gap in literature, the immunostaining values (semiquantitative evaluation of protein expression: SI, staining intensity; PP, percentage of positive cells; and IR score, immunoreactivity score) of NGF and TrkA proteins were examined in human scalp skin by immunofluorescent and immunoperoxidase staining methods. Fifty normal human scalp skin biopsy specimens were examined (healthy females, 53-57 years). In each case, 50 HFs were analyzed (35, 10, and five follicles in anagen, catagen, and telogen, respectively). RESULTS: The IR scores were statistically significantly higher (p < 0.001) in anagen as compared with either catagen or telogen HF (9.61 +/- 0.12 vs. 1.4 +/- 0.10 vs. 0.6 +/- 0.10 for NGF and 3.31 +/- 0.02 vs. 0.5 +/- 0.10 vs. 0.2 +/- 0.10 for TrkA). In the anagen HF, high expression values were seen in the distal region, followed by upper distal, lower distal, and bulb regions for both NGF (10.6 +/- 0.21 vs. 10.3 +/- 0.21 vs. 9.2 +/- 0.40 vs. 8.1 +/- 0.30) and TrkA (3.54 +/- 0.07 vs. 3.45 +/- 0.07 vs. 3.31 +/- 0.06 vs. 3.13 +/- 0.04). Both NGF and TrkA proteins showed prominent expression in the melanocytes (7.6 +/- 0.15 vs. 2.50 +/- 0.07), keratinocytes (10.2 +/- 0.40 vs. 2.71 +/- 0.06), sebaceous glands (10.2 +/- 0.40 vs. 2.72 +/- 0.06), and sweat glands (10.4 +/- 0.40 vs. 2.84 +/- 0.05). CONCLUSIONS: Our findings report, for the first time, the expression pattern of NGF and TrkA proteins in human scalp skin and HF. The differential expression of these proteins during HF cycling suggests their possible roles in human HF biology. The clinical ramifications of these observations mandate further investigations.

Biopsy↗

Ossifying fibromyxoid tumor of soft parts presenting as a scalp cyst.

BACKGROUND: Ossifying fibromyxoid tumor of soft parts (OFMT) is a rare mesenchymal neoplasm of intermediate malignant potential. The tumor most commonly occurs on the extremities with a male predominance. We present an unusual case of OFMT occurring as a cystic lesion on the scalp of a female. CASE HISTORY: A 67-year-old woman presented with a 6-year history of a well demarcated cystic scalp mass. Physical examination revealed a slightly movable, multilobular mass of the left parietal scalp which was subsequently excised. Histological evaluation revealed an OFMT comprised of bland, small cells and a thick collagenous capsule containing an incomplete rim of lamellar bone. CONCLUSION: OFMT is an unusual tumor which can usually be considered as having an intermediate risk of malignancy. It generally occurs in the extremities with a male predominance. The clinical differential for a cystic mass on the scalp is broadened by this unusual case of an OFMT.

Aged↗

[Ulceration of the scalp: a unique manifestation of pyoderma gangrenosum].

Pyoderma gangrenosum is a chronic, noninfectious, ulcerating cutaneous disease of unknown etiology usually presenting with multiple lesions on the legs and trunk. Solitary lesions in other locations are rare and therefore hard to diagnose. A 78-year-old and a 81-year-old woman with extensive scalp necrosis were both diagnosed as pyoderma gangrenosum after exclusion of other differential diagnostic possibilities. The separate diagnosis of malignant pyoderma for this disease state no longer seems justified. Scalp necrosis is infrequently seen in dermatological patients; most previous reports describe it in giant cell arteritis. Other differential diagnoses include viral, bacterial and mycotic infections as well as erosive pustular dermatosis of the scalp. In conclusion, we again draw attention to unilesional pyoderma gangrenosum of the scalp as a rare disease entity. Immunosuppressive drugs are an effective treatment modality.

Aged↗

Expression of CD1d in human scalp skin and hair follicles: hair cycle related alterations.

BACKGROUND: CD1d belongs to a family of antigen presenting molecules that are structurally and distantly related to the classic major histocompatibility complex class I (MHC I) proteins. However, unlike MHC I molecules, which bind protein antigens, CD1d binds to lipid and glycolipid antigens. CD1d is expressed by cells of lymphoid and myeloid origin, and by cells outside of the lymphoid and myeloid lineages, such as human keratinocytes of psoriatic skin. AIMS: To investigate whether CD1d is also expressed in sun exposed skin and in the immuno-privileged anagen hair follicle. MATERIALS/METHODS: CD1d immunoreactivity was studied in human scalp skin and hair follicles of healthy women in situ by immunofluorescent and light microscopic immunohistology. Skin biopsies were obtained from normal human scalp containing mainly anagen VI hair follicles from women (age, 53-57 years) undergoing elective plastic surgery. RESULTS: CD1d showed strong immunostaining in human scalp skin epidermis, pilosebaceous units, and eccrine glands. In the epidermis, CD1d was strongly expressed by basal and granular keratinocytes. In hair follicles, CD1d was expressed in the epithelial compartment and showed hair cycle related alterations, with an increase in the anagen and a reduction in the catagen and telogen phases. CONCLUSIONS: These results suggest that CD1d plays a role in human scalp skin immunology and protection against lipid antigen rich infectious microbes. They also raise the question of whether keratinocytes of the immuno-privileged anagen hair follicle can present lipid antigens to natural killer T cells. These data could help provide new strategies for the manipulation of hair related disorders.

Antigens, CD1↗

Calcipotriol solution for the treatment of scalp psoriasis: evaluation of efficacy, safety and acceptance in 3,396 patients.

BACKGROUND: Psoriasis of the scalp is a very common disease, cosmetically disturbing and therapeutically difficult to manage. OBJECTIVE: The aim of our study was to investigate the efficacy, safety and cosmetic acceptance of calcipotriol solution in a large number of patients with mild to moderate scalp psoriasis and to compare this treatment with previous therapies used. METHODS: In this multicentre prospective observational cohort study 3,396 patients were treated with calcipotriol solution (50 microg/ml) twice daily over an 8-week period either alone or in combination with other treatments. The psoriasis scalp severity index (PSSI) and investigator/patient global assessment were used for the evaluation of clinical response. RESULTS: All psoriasis severity parameters measured were reduced with a significant decrease in PSSI scores from 18.4 to 5.6 after 8 weeks of therapy (p < 0.001). About 80% of the patients showed very good or good clinical improvement. Combination of calcipotriol solution with other treatment modalities e.g. corticosteroids or salicylic acid, showed an increased treatment response. In only 2.4% of the patients side effects occurred (e.g. irritation). CONCLUSION: Calcipotriol solution is an effective, safe, well-tolerated and cosmetically acceptable treatment modality. By patients and physicians, this treatment was found to be a valuable supplement to previously available and established treatments for scalp psoriasis.

Adult↗

Erosive pustular dermatosis of the scalp: a case report and review of the literature.

Erosive pustular dermatosis of the scalp (EPDS) is a rare entity characterized by pustular, erosive and crusted lesions of the scalp with progressive scarring alopecia. The aetiology is unknown, but predisposing factors have been reported such as trauma, skin grafting, prolonged exposure to UV light of a bald scalp as well as co-existence of auto-immune diseases. Laboratory data, bacteriological and mycological investigations and histopathology are generally not diagnostic. A 45-year-old Caucasian man with 1-year-old pustular, erosive and crusted lesions on his bald scalp was seen. Laboratory data, including auto-immunity, bacteriological and mycological investigations were negative. Histopathology was not diagnostic showing a diffuse polymorphous infiltrate involving the dermis. A diagnosis of EPDS was made. The patient was treated with topical and systemic antibiotics and steroids as well as oral nimesulide with no or partial response. Consequently, isotretinoin (0.75 mg/kg/day) was started obtaining complete resolution in few months. No relapse after 1 year of follow-up was seen. EPDS represents a distinct disease with a history of relapsing and unsatisfactory response to common treatments. Systemic retinoids may be considered as a potentially resolutive choice.

Administration, Topical↗

Shaving of the scalp may increase the rate of infection in CSF shunt surgery.

Hydrocephalic patients undergo repetitive surgical procedures, most of which involve the scalp. 141 shaveless operations involving scalp incisions for cerebrospinal fluid (CSF) shunts as well as 218 historical controls were reviewed after the senior author ceased shaving the scalp. The study population has been followed for a mean of 13.4 months and the control population for a mean of 38.6 months. The actuarial rate of infection at 1 year was 3.3% in the study population and 6.9% in the control population. Anesthesia times were not significantly different. Shaving of the scalp is not a critical step in the prevention of CSF shunt infection.

Cerebrospinal Fluid Shunts↗

Psoriatic alopecia: acute and chronic hair loss in 47 patients with scalp psoriasis.

Symptomatic hair loss and alopecia were seen in psoriatic lesions of the scalp in 47 patients. Remarkably, in 66% of the cases it was an inaugural manifestation, and in 36% the scalp was exclusively involved. Therefore 34% of the patients presented with a primary manifestation of isolated scalp psoriasis. Hair loss varied in intensity from protracted to moderate and massive (36% in tufts). It presented as acute (51%), chronic (36%) or chronic recurrent (13%). Thirteen patients (28%) became aware of the hair loss with the beginning of therapy. The alopecia was found to be circumscribed in 75% of the cases and diffuse in 25%. In 2 cases psoriatic alopecia also manifested itself at sites other than the scalp. The telogen count was found to be increased up to 25-86% in the florid stage. Examinations under the light microscope showed a patchy perifollicular lymphohistiocytic infiltrate in the upper and middle dermis with adnexotropia in several cases. This infiltrate can alter the follicle epithelium and may lead to a granulomatous foreign-body reaction with destruction of the hair follicle. After topical antipsoriatic treatment, most of the reexamined patients showed complete hair regrowth, while 5 developed a residual scarring. Therefore, in the patient with circumscribed or diffuse symptomatic alopecia, with or without scarring, psoriatic alopecia should be considered.

Acute Disease↗

Scalp hypothermia: a comparison of ice packs and the Kold Kap in the prevention of doxorubicin-induced alopecia.

Two methods of scalp hypothermia were compared in preventing alopecia, a side effect of doxorubicin chemotherapy that has a significant psychologic impact on the patient. Thirty-three patients received scalp ice packs consisting of crushed ice in plastic bags. Twenty-nine patients received Kold Kap, a device that produces chilling via an endothermic reaction. Scalp hypothermia was applied for 5-10 min before the doxorubicin bolus and left in place for 30-40 min afterward. The percent of hair loss was rated at each visit and photographs were used to further quantitate any hair loss. Sixty-three percent of Kold Kap and 56% of ice pack patients had good or better protection and did not require wigs. Excellent protection (less than 25% loss) was provided for 51% of Kold Kap and 33% of ice pack patients. Similar protection was provided to Kold Kap patients regardless of dose, while ice pack patients received significantly better protection if their doxorubicin doses were less than 50 mg. Scalp hypothermia is an effective method of preventing doxorubicin-induced alopecia.

Alopecia↗