Begell House Inc.
Journal of Long-Term Effects of Medical Implants
JLT
1050-6934
14
3
2004
Modern Concepts in the Diagnosis and Treatment of Sleep Apnea
2
10.1615/JLongTermEffMedImplants.v14.i3.10
Thomas J.
Gampper
Associate Professor of Plastic Surgery, Department of Plastic Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA
Obstructive Sleep Apnea: Part I. Pathophysiology, Diagnosis, and Medical Management
10
10.1615/JLongTermEffMedImplants.v14.i3.20
James J.
Carswell
Division of Pulmonary Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
Steven M.
Koenig
Division of Pulmonary Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
Obstructive sleep disordered breathing (OSDB) is a spectrum of disease resulting from changes in the upper airway. It affects a large proportion of the adult population, and in its most severe form, obstructive sleep apnea syndrome (OSAS), patients suffer the adverse effects of sleep disturbance and oxygen desaturation. Daytime somnolence leads to a significantly higher incidence of automobile and work-related accidents, while nocturnal hy-poxia is associated with multiple physiological derangements. Patients with OSAS have higher incidences of hypertension, coronary artery disease, congestive heart failure, and arrhythmias. Noninvasive testing is used to confirm the diagnosis, and treatment may be conservative, medical, or surgical. Treatment is designed to improve daytime somnolence and has been shown to improve morbidity and mortality among patients with OSDB.
Obstructive Sleep Apnea: Part II. Surgical Approaches to Sleep Apnea
8
10.1615/JLongTermEffMedImplants.v14.i3.30
Jeremy A.
Benedetti
Department of Plastic and Maxillofacial Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
Martin
Hoard
Department of Plastic and Maxillofacial Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
Thomas J.
Gampper
Associate Professor of Plastic Surgery, Department of Plastic Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA
Successful surgical management of obstructive sleep apnea (OSAS) requires a thorough understanding of the pathophysiology and anatomical contributions to this widely variable disease. Early efforts to surgically correct OSAS involved bypassing the upper airway; thus, indirectly improving the symptoms without directly addressing the pathophysiology. Surgical procedures to treat OSAS have evolved over the past several decades as further understanding of the disease continues to be elicited.The surgical techniques employed in the treatment of OSAS are quite varied. Many surgical subspecialties have contributed to the understanding of the complexities of OSAS. Recent surgical management involves site-specific alterations of the upper airway to more directly address the disease process. In addition, current literature suggests an algorithmic and phased approach to the treatment of OSAS. Future technology offers the hope of better diagnostic and therapeutic options for the surgical management of OSAS.
Biopsy of Lesions of the Female Genital Tract in the Ambulatory Setting
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10.1615/JLongTermEffMedImplants.v14.i3.40
William Paul
Irvin, Jr.
Associate Professor, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA, USA
Peyton T.
Taylor, Jr
Richard N. & Louise R. Crockett Professor of Ohstetrics & Gynecology; Medical Director, Cancer Center. University of Virginia Health System P.O. Box 800712 Charlottesville VA 22908, USA
The organs of the female genital tract (vulva, vagina, cervix, uterus, ovaries, and fallopian tubes) are capable of elaborating an immense array of pathologic conditions. These conditions can be primarily infectious in nature, or they can be neoplastic, precancerous, or frankly cancerous. In most instances the patient's history and physical examination alone are insufficient to establish a diagnosis, given the extreme similarity in clinical presentation of the various abnormalities of the female genital tract and the subtle differences that distinguish one from the other. In order to definitively establish the diagnosis, it is often necessary to obtain a tissue sample. Most clinicians are intimidated at the prospect of performing a biopsy of the lower female genital tract given concerns for patient discomfort and bleeding, in conjunction with a lack of familiarity with the specific techniques and instruments available to perform these biopsies. Conditions may go undiagnosed, or there may be a significant delay in diagnosis, as a result. In fact, failure to biopsy and obtain an accurate diagnosis in a timely fashion is a major concern from the medicolegal perspective. There is an increasing emphasis upon ambulatory care in our society. For this reason, it is essential that the clinician be familiar with the techniques that permit safe and reliable tissue diagnosis in the outpatient setting. This article is intended to describe the various techniques available to biopsy the organs of the female genital tract, as well as the instruments designed and uniquely suited for that purpose. An extensive Medline search was performed from the years 1965—2003, cross-referencing the terms "biopsy techniques" and "organs of the female genital tract." The results of this analysis detail both incisional and excisional biopsy techniques that can be safely employed by the clinician in the out-patient or ambulatory settings to obtain tissue samples to aid in initial diagnosis, or to accomplish therapeutic excision in order to definitively address a previously known condition. Being aware of the various biopsy techniques available for the outpatient evaluation of the female genital tract, and being comfortable with their use, increases the likelihood that abnormalities of the reproductive organs will be expeditiously evaluated, accurately diagnosed, and appropriately treated in a timely fashion.
Excisional Biopsy of Skin Tumors
14
10.1615/JLongTermEffMedImplants.v14.i3.50
Richard
Edlich
Legacy Verified Level I Shock Trauma Center Pediatrics and Adults, Legacy Emanual Hospital; and Plastic Surgery, Biomedical Engineering and Emergency Medicine, University of Virginia Health System, USA
Daniel G.
Becker
Associate Professor, Director of Facial Plastic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania Medical Center Founder, Becker Nose and Sinus Center, LLC, Sewell, NJ, USA
William B.
Long III
Trauma Specialists LLP, Legacy Verified Level I Shock Trauma Center for Pediatrics and Adults, Legacy Emmanuel Hospital, Portland, OR, USA
Thomas M.
Masterson
Internal Medicine and Nephrology. President. International Medical Publishing, Inc. 1313 Dolly Madison Blvd., Suite 302 McLean VA 22101; and Trauma Services, Legacy Emanuel Hospital, Portland, Oregon, USA
The most frequently encountered neoplasm in the US is skin cancer. More than 600,000 new cases of malignant skin tumors are diagnosed in the US each year. One standard method of treatment of skin tumors is excisional biopsy. There are seven technical considerations involved in the excisional biopsy of skin tumors: (1) aseptic technique, (2) examination and demarcation of skin lesion, (3) skin biomechanical properties, (4) anesthesia, (5) excisional biopsy, (6) wound closure, and (7) postoperative care.The physician must use aseptic techniques and wear a cap, mask, and powder-free gloves. Hair is a source of wound contamination, and removal of hair prevents it from becoming entangled in suture and the wound during closure. Because surgical electric clippers cut hair close to the skin surface without nicking the skin, we now use only electric clippers to remove hair. The physician’s visualization of the wound can be enhanced by magnification (2.5x) loupes. The physician’s plan for excisional biopsy is dictated by the suspected pathology of the skin lesion. The ultimate appearance and function of a scar after closure of excisional biopsy can be predicted by the static and dynamic skin tensions on the surrounding skin. Infiltration anesthesia is preferred over regional nerve block because it does not interfere with the muscle movement that causes dynamic tensions, which elongate the configuration of the defect. Most skin lesions are amenable to a circular excision. In these instances, it is worthwhile to use circular-shaped excisions. The reusable metal trephines have been replaced by disposable trephines that have ribbed plastic handles attached to 316 stainless steel circular cutting blades. Wound closure is accomplished in the same direction as the long axis of the elliptical defect by first approximating the midportion of the defect with a 4-0 synthetic CAPROSYN* monofila-ment absorbable suture attached to the swage of the laser-drilled, compound-curved reverse cutting edge needle. Additional interrupted dermal (subcuticular) sutures are placed in each wound quadrant to approximate further the divided edges of the dermis. Compound-curved reverse cutting edge needles have been specifically designed for dermal closure. Reinforced Steri-Strips are then applied transversly across the incision to facilitate further skin edge approximation. Rigorous follow-up examination is essential for any patient with a history of a skin cancer to detect recurrence and prevent further actinic damage. The use of wide diameter trephine biopsy instruments are still not widely used by physicians because most physicians do not have the technical skills to approximate the defect with dermal sutures. Consequently, this need for a rapid dermal skin closure technique that can be used by a primary care physician must be devised before the trephine excisional biopsy technique is widely used by the primary care physician. This goal can be achieved by developing a disposable stapler for subcuticular closure of the skin.
National Health Strategies to Reduce Sun Exposure in Australia and the United States
10
10.1615/JLongTermEffMedImplants.v14.i3.60
Richard
Edlich
Legacy Verified Level I Shock Trauma Center Pediatrics and Adults, Legacy Emanual Hospital; and Plastic Surgery, Biomedical Engineering and Emergency Medicine, University of Virginia Health System, USA
Kathryne L.
Winters
Website Manager and Information Specialist, Trauma Specialists, LLP, Legacy Emanuel Hospital, Portland, OR, USA
Mary Jude
Cox
Glaucoma Service, Eye Physicians of Southern New Jersey, Voorhees, NJ, USA; Department of Physical Medicine & Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
Daniel G.
Becker
Associate Professor, Director of Facial Plastic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania Medical Center Founder, Becker Nose and Sinus Center, LLC, Sewell, NJ, USA
Jed H.
Horowitz
Pacific Center for Plastic Surgery & Plastikos Foundation, Huntington Beach, California, USA
Larry S.
Nichter
Pacific Center for Plastic Surgery, Huntington Beach, CA, USA
L.D.
Britt
Chairman, Brickhouse Professor of Surgery, Department of General Surgery, Eastern Virginia Medical School, Hofheimer Hall, 825 Fairfax Ave., Norfolk, VA 235001, USA
Theodore J.
Edlich III
Total Action Against Poverty, Roanoke, Virginia
William B.
Long III
Trauma Specialists LLP, Legacy Verified Level I Shock Trauma Center for Pediatrics and Adults, Legacy Emmanuel Hospital, Portland, OR, USA
Australia has developed a national health care policy that has made prevention of the occurrence of skin cancer a societal responsibility. Its strategies for skin cancer control have included careful documentation of the incidence of skin cancer over the last two decades. After realizing that the magnitude of sun exposure during childhood is a major risk factor in the development of skin cancer, Australia provides successful strategies to monitor and reduce the frequency of skin cancer. Early in the 1970s, education campaigns for the public as well as the healthcare worker were implemented that included booklets, posters, and teaching materials. This educational program allowed the public as well as healthcare workers to diagnose accurately the presence of skin cancer. In addition to identifying tumors at an early stage, Australia managed an exciting educational program on photodamage prevention. Australian standards governing ultraviolet radiation protection were incorporated into numerous comprehensive legislative bills that set standards for a wide variety of sun protective products to include sunscreens, photoprotective apparel, sunglasses, and occupational standards for sun exposure. On the basis of these comprehensive standards, the epidemic of skin cancer has been curbed, as documented. In contrast to Australia, the United States has relatively few comprehensive skin cancer prevention programs. These programs include the National Skin Cancer Prevention Educational Program, National Skin Cancer Prevention and Detection Month, The Skin Cancer Foundation's Self-Examination Program, and the State of California and US Food and Drug Administration Sunscreen legislation. It is difficult to measure the impact of these innovative efforts because there is not an accurate monitoring system for all skin cancers in the United States. However, the National Cancer Institute does determine the incidence of melanoma, which is reported annually by the American Cancer Society in their January/February issue of CA Journal for Clinicians. Statistics on other skin cancers are only projective. In the absence of an accurate, comprehensive statistical monitoring system for the frequency of skin cancer in the United States, as well as the limited legislative initiatives, it is difficult for organizations such as the American Academy of Dermatology, the American Cancer Society, the Centers for Disease Control and Prevention, and The Skin Cancer Foundation to ascertain the results of their efforts to prevent skin cancer. Consequently, the prevention of skin cancer in the United States is a personal rather than a societal responsibility.
Histologic and Hemodynamic Effects of Endosaccular Platinum Coils for Intracranial Aneurysms
18
10.1615/JLongTermEffMedImplants.v14.i3.70
Alex M.
Barrocas
Department of Neurology, Georgetown University, Washington DC; and Ilnterventional Neuroradiology Service, Mallinckrodt Institute of Radiology, St. Louis, Missouri,USA
Colin P.
Derdeyn
Associate Professor of Radiology and Neurology. Mallinckrodt Institute of Radiology 510 South Kings Highway Blvd. St. Louis MO 63110; and Departments of Neurology and Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
DeWitte T.
Cross III
Interventional Neuroradiology Service, Mallinckrodt Institute of Radiology; and Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
Christopher J.
Moran
Interventional Neuroradiology Service, Mallinckrodt Institute of Radiology; and Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
Ralph G.
Dacey Jr.
Henry G. & Edith R. Schwartz Professor; Chairman of Neurological Surgery . Washington University School of Medicine 660 S. Euclid Avenue, Campus Box 8057 St. Louis MO 63110
Over the past 15 years, endosaccular platinum coil therapy for intracranial aneurysms has evolved from clinical pilot studies of investigational devices to common clinical practice. The mechanism by which these coils reduce the risk of aneurysm rupture—the primary goal of intracranial aneurysm treatment—is the focus of this review. Both histological mechanisms of scar formation and hemodynamic mechanisms of flow diversion may be involved. We will first review aneurysm epidemiology to provide the context and rationale for therapy for patients harboring intracranial aneurysms. Next, we will review the data for and theories of the pathophysiology of aneurysm formation, growth, and rupture, particularly as they relate to endovascular coil therapy. Histological and hemodynamic studies of coiled aneurysms in animals and humans will be reviewed. Fınally, we will discuss emerging coil-based therapies, such as bioactive polymer coatings for platinum coils and the adjunctive use of stents.
Government and Private Insurance Medical Programs as well as MDVIP, an Update
8
10.1615/JLongTermEffMedImplants.v14.i3.80
Richard
Edlich
Legacy Verified Level I Shock Trauma Center Pediatrics and Adults, Legacy Emanual Hospital; and Plastic Surgery, Biomedical Engineering and Emergency Medicine, University of Virginia Health System, USA
Gloria
Anima
Plastic Surgery Research Program, University of Virginia Health System, Charlottesville, Virginia, USA
Kathryne L.
Winters
Website Manager and Information Specialist, Trauma Specialists, LLP, Legacy Emanuel Hospital, Portland, OR, USA
L.D.
Britt
Chairman, Brickhouse Professor of Surgery, Department of General Surgery, Eastern Virginia Medical School, Hofheimer Hall, 825 Fairfax Ave., Norfolk, VA 235001, USA
William B.
Long III
Trauma Specialists LLP, Legacy Verified Level I Shock Trauma Center for Pediatrics and Adults, Legacy Emmanuel Hospital, Portland, OR, USA
On November 19,1945, President Truman outlined a Prepaid Medical Insurance Plan for all people through the Social Security System. Because of its comprehensive nature, it was coined "National Health Insurance." On July 30,1965, President Johnson signed the Medicare and Medicaid bill (Title XVII & Title XIX of the Social Security Act). Today, many groups of people are covered by Medicaid. However, there are strict requirements that may vary from state to state. Medicare offers the following types of medical heath care plans to include the original Medicare plan that is a "fee for service" plan. The individual may stay in the original plan unless he/she chooses to join a Medicare+ Choice Plan or a Medigap Plan. Most individuals will receive Medicare Part A when they are 65 without paying a premium because it has been deducted annually through their tax payments before the age of 65. Medicare Part A helps pay for the following: inpatient hospital care, skilled nursing facility, hospice care, and some home health care. Medicare Part B, however, must be paid by the individual through premiums to the Federal government. Medicare Part B medical insurance pays for doctors' services, outpatient services, and some other services that Medicare Part A doesn't cover. In an effort to supplement one's health care coverage, the individual may select either a Medicare+ Choice Plan or a Medigap Policy. The Medicare+ Choice Plan has four different types: Medicare Managed Care Plans, Medicare Private Fee for Service Plan, Medicare Preferred Provider Plans, and Medicare Specialty Plans. If one selects a Medigap policy, one may choose either a Medigap SELECT Policy or the standard Medigap policy. The front of a Medigap Policy must clearly identify it as a "Medicare Supplement Insurance." One must be carefully advised of the selection of the Medigap Policy. The Medicare Part B has a wide range of preventative services, including tests for breast cancer, cervical cancer, vaginal cancer, and colorectal cancer; bone mass measurements; diabetes monitoring and diabetes self-management; flu, pneumonia, Hepatitis B shots, and prostate cancer screening tests. It is important to emphasize that Medicare and Medicare supplemental insurance policies do not pay for home health care, such as durable medical equipment. Because of the enormous complexity of the wide variety of health insurance plans and their billing strategies, many physicians are electing to charge their patients an additional fee for being part of their practice. In return for their annual fee, their patients receive immediate cell phone access to their doctor 24 hours a day, 7 days a week. In addition, they receive same-day appointments and on-time appointments. They also spend as much time with their doctors as they wish. It is not surprising that there is growing evidence that the privately insured patient with a life-threatening illness will live longer than those individuals who have the same disease but have public insurance only. Legislatures are well aware of this crisis in medical care that must be corrected immediately.
Experimental Studies in Swine for Measurement of Suture Extrusion
10
10.1615/JLongTermEffMedImplants.v14.i3.90
David B.
Drake
Associate Professor of Plastic Surgery & Orthopedic Surgery, University of Virginia Health System, PO Box 800376, Charlottesville, VA 22908, USA
Pamela E.
Rodeheaver
Department of Plastic Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA
Richard
Edlich
Legacy Verified Level I Shock Trauma Center Pediatrics and Adults, Legacy Emanual Hospital; and Plastic Surgery, Biomedical Engineering and Emergency Medicine, University of Virginia Health System, USA
George T.
Rodeheaver
Plastic Surgery Research Program, Department of Plastic Surgery, University of Virginia Health System, Charlottesville, VA, USA
The purpose of this scientific investigation was to identify the determinants of suture extrusion following subcuticular skin closure of dermal skin wounds. Miniature swine were used to develop a model for studying suture extrusion. Standard, full-thickness skin incisions were made on each leg and the abdomen. The wounds were closed with size 4/0 POLYSORB* or COATED VICRYL* sutures. Each incision was closed with five interrupted, subcuticular, vertical loops secured with a surgeon's knot. The loops were secured with 3-throw knots in one pig, 4-throw knots in the second pig, and 5-throw knots in the third pig. The swine model reproduced the human clinical experience and suture extrusion, wound dehiscence, stitch abscess, and granuloma formation were all observed. The cumulative incidence of suture extrusion over 5 weeks ranged from 10 to 33%. COATED VICRYL* sutures had a higher mean cumulative incidence of suture extrusion than that of POLYSORB* sutures (31% vs. 19%).With POLYSORB* sutures, the 5-throw surgeon's knots had a higher cumulative incidence of suture extrusion than the 3-throw or 4-throw surgeon's knot square, 30% vs. 17% and 10%, respectively. This swine model offers an opportunity to study the parameters that influence suture extrusion. Because the volume of suture material in the wound is obviously a critical determinant of suture extrusion, it is imperative that the surgeon construct a knot that fails by breakage, rather than by slippage with the least number of throws. Because both braided absorbable suture materials are constructed with a secure surgical knot that fails only by breakage rather than slippage with a 3-throw surgeon's knot square (2 = 1 = 1), the construction of additional throws with these sutures does not enhance the suture holding capacity but plays a key factor in precipitating suture extrusion. Finally, it is important to emphasize that the surgeon must always construct symmetrical surgical knots for dermal subcuticular skin closure in which the constructed knot is always positioned perpendicular to the linear wound incision. Asymmetrical knot construction for dermal wound closure becomes an obvious invitation for suture extrusion.