Ungual melanoma - controversies in diagnosis and treatment

Ungual melanomas are considered rare, being difficult to diagnose, and having a poor prognosis. The aim of the present study was to discuss the epidemiology, potential causes, treatment options, and outcome of ungual melanomas. In contrast to assumptions in many articles, ungual melanomas are not rare when calculated for the cumulative size of the nail apparatus of both the fingers and toes. The prognosis is not worse than that of melanomas with the same thickness, mitotic rate, or presence of ulceration on other sites. Melanomas of the nail apparatus behave similar to melanomas in other localizations. What makes them enigmatic is the high rate of misdiagnoses and very late diagnoses.

Endovascular treatment of arterial injury as an uncommon complication after orthopedic surgery

PURPOSE: To evaluate selective and superselective catheter therapy of serious arterial damage associated with orthopedic surgery of the pelvis, hip joint, femur, and knee. MATERIALS AND METHODS: Between 1989 and 2005, 16 consecutive patients with arterial damage after orthopedic surgery (seven women, nine men; mean age, 62 years; age range, 21-82 y) underwent angiographic exploration. Seven patients were in hemodynamically unstable condition. Initial orthopedic procedures were iliac crest internal fixation (n = 1); total hip prosthesis (n = 3); revision of total hip prosthesis (n = 4); revision of acetabular cup prosthesis (n = 1); gamma-nailing, nail-plate fixation, or intramedullary nailing (n = 3); and total knee prosthesis (n = 4). RESULTS: Angiography showed pseudoaneurysms (n = 11), vascular lacerations with active extravasation (n = 3), and arteriovenous fistulas with extravasation (n = 2). After angiographic documentation of serious arterial injury, 14 patients were treated with a single or coaxial catheter technique in combination with coils alone, coils and polyvinyl alcohol particles, coils and Gelfoam pledgets, or Gelfoam pledgets; or balloon occlusion with isobutyl cyanoacrylate and coils. Two patients were treated with covered stents. In all, bleeding was effectively controlled in a single session in 16 patients, with immediate circulatory stabilization. Major complications included death, pulmonary embolism, and postprocedural hematoma. CONCLUSION: Selective and superselective catheter therapy may be used for effective, minimally invasive management of rare but potentially life-threatening vascular complications after orthopedic surgery.

Silhouettella loricatula (Arachnida, Araneae, Oonopidae): a Haplogyne spider with complex female genitalia

The female genital system of the oonopid Silhouettella loricatula is astonishingly complex. The genital opening is situated medially and leads into an oval receptaculum that is heavily sclerotized except for the ventral half of the posterior wall that appears chitinized only. A large striking sclerite lying in the posterior wall of the uterus externus is attached anteriorly to the receptaculum and continues dorsally into a globular appendix that bears a furrow. The uterus externus shows a peculiar modification in its anterior wall: a paddle-like sclerite with a nail-like posterior process. This sclerite lies opposite to the furrow proceeding in the globular appendix and may serve females to lock the uterus externus by muscle contractions. Massive muscles connect the sclerite with the anterior scutum of the opisthosoma and with two other sclerites that are attached to the receptaculum and serve as attachments for further muscles. Gland cells extend around a pore field of the receptaculum. They produce secretion that encloses spermatozoa in a discrete package (secretory sac) inside the receptaculum. In this way, the mixing of sperm from different males and thus sperm competition may be severely limited or completely prevented. During a copulation in the laboratory the ejection of a secretory sac that most probably contained spermatozoa was observed, indicating sperm dumping in S. loricatula. The ejection of the secretory sac may be caused by female muscle contractions or by male pedipalp movements. The majority of the investigated females have microorganisms in the receptacula that could represent symbionts or infectious agents. The microorganisms can be identified partly as bacteria. They are enclosed in secretion and are always found in the same position inside the receptaculum.

Onychocosmeceuticals

The nail is the largest skin appendage. In addition to its important physiological and sensory functions, it is also of great esthetic importance. Complaints of brittle or soft nails are frequent, particularly among women. Innumerable preparations claiming to improve the nail quality are being sold; however, most have no proven beneficial effect. Also, surgery cannot enhance nail quality but improve shape and size abnormalities.

Onychomycosis: The Current Approach to Diagnosis and Therapy, 2nd Edition

This new edition of a bestselling text illustrates the changes in attitudes towards fungal nail infections: previously attracting little interest, with a reputation for stubborn resistance to treatment, they have now reached the stage where there has been enormous recent scientific and medical progress, bringing with it a real possibility for a successful outcome of therapy for a growing population of patients. With this process has come the realization that there is now a clear choice of treatment determined by rational medical assessment. This book has been written by clinicians for clinicians, to provide a guide to the steps needed to identify and effectively manage the patient with onychomycosis. It is the first title in a new Series in Dermatological Therapy launched in conjunction with the Journal of Dermatological Therapy.

Short-term effects of hygiene education for preschool (kindergarten) children: a clinical study

AIM: To evaluate the outcomes of short (15 minutes) oral hygiene vs. hand hygiene education for preschool children 4 weeks after these interventions. MATERIALS AND METHODS: Sixty-one preschool children (age range 4-6 years) attending four kindergarten classes participated in a 15-minute health education programme on the importance of body cleanliness for general health. In addition, specific instructions on oral hygiene were provided for two randomly selected classes (30 children), while the remaining two classes (31 children) were given instruction of hand and nail cleaning. The oral hygiene status was assessed usingthe plaque control record (PCR). The cleanliness of the hands and fingernails was determined using a hand hygiene index (HHI) and a nail hygiene index (NHI). All three parameters were assessed before the intervention as well as 4 weeks thereafter. RESULTS: Four weeks after education, the PCR had improved for all children from 79.95% to 72.35% (p < 0.001). The NHI had improved from 74.91% to 61.71% (p < 0.001). In addition, the mean PCR of the children given oral hygiene instruction decreased from 83.67% to 72.40%, while the mean PCR of the children given hand and nail cleaning instruction decreased from 76.23% to 72.29% (interaction effect 'time x type of instruction': p = 0.044). Girls' PCR improved significantly more than boys' PCR (Girls, 80.98 vs. 69.71; boys, 78.33 vs. 75.31; p = 0.021). CONCLUSIONS: The results of the study show that even a short, school-based educational intervention at an early age may affect children's oral health promotion significantly. Teachers should, therefore, be encouraged to educate children from an early age about oral hygiene promotion.

Precise pose recovery of distal locking holes from single calibrated fluoroscopic image via a novel variable decomposition approach

This paper presents a novel variable decomposition approach for pose recovery of the distal locking holes using single calibrated fluoroscopic image. The problem is formulated as a model-based optimal fitting process, where the control variables are decomposed into two sets: (a) the angle between the nail axis and its projection on the imaging plane, and (b) the translation and rotation of the geometrical model of the distal locking hole around the nail axis. By using an iterative algorithm to find the optimal values of the latter set of variables for any given value of the former variable, we reduce the multiple-dimensional model-based optimal fitting problem to a one-dimensional search along a finite interval. We report the results of our in vitro experiments, which demonstrate that the accuracy of our approach is adequate for successful distal locking of intramedullary nails.

Systemsklerose

Die Systemsklerose ist charakterisiert durch autoimmune Phänomene und eine progressive Fibrose. Klinische Charakteristika sind neben der Sklerodermie ein ausgeprägtes Raynaud-Phänomen und Abnormitäten der Nagelfalzkapillaren, ferner pulmonale, renale, kardiale und intestinale Veränderungen. In der Regel wird eine diffuse von einer limitierten Form unterschieden. Die diffuse Form führt zu einer Sklerose des gesamten Integumentes, ist assoziiert mit dem Auto-antikörper Scl-70 und zeichnet sich durch eine rasche Krankheitsprogression aus. Die limitierte Form betrifft die distalen Extremitäten und das Gesicht, ist assoziiert mit dem centromer Autoantikörper und führt schleichend, über mehrere Jahre zu viszeralen Problemen. Neue therapeutische Möglichkeiten können zu einer besseren Lebensqualität verhelfen und verpflichten zu einem systematischen Krankheitsmonitoring.

Intramedullary nails for pediatric diaphyseal femur fractures in older, heavier children: early results

PURPOSE A common treatment for pediatric femur fractures is intramedullary nail (IMN) insertion. Elastic stable intramedullary nails (ESINs) are often used for these procedures in heavier patients, but the potential for complications and malunion is greater. We describe here a rigid IMN specifically designed for adolescents, the adolescent lateral entry femoral nail (ALFN). The purpose of this study was to compare the recovery and complications for patients treated with ESINs to those treated with the ALFN. METHODS Our study design was a retrospective cohort study. We performed a review of medical records of 22 children ages 10-17 requiring surgical fixation of a femur fracture for a 2½-year period. Patients selected for the study had traumatic diaphyseal femur fractures and were treated with ESINs without end-caps or ALFNs. Our analyses evaluated injury, surgical, and outcome information for all patients. RESULTS Twenty-two patients were eligible for inclusion and were divided into two groups according to their treatment: the ESIN group with 7 patients and the ALFN group with 15 patients. We then performed a comparison of complications and recovery for these patients. The mean time to full weight-bearing was significantly less for the ALFN group (4.1 weeks; SD, 2.2), than the ESIN group (9.4 weeks; SD 3.9). There was no statistical difference in the incidence of major or minor complications. CONCLUSIONS Older, heavier pediatric patients treated for femur fracture with ALFNs had a shorter recovery time than similar patients treated with ESINs. However, the outcomes for both groups were satisfactory.

A Nonsense Mutation in the IKBKG Gene in Mares with Incontinentia Pigmenti.

Ectodermal dysplasias (EDs) are a large and heterogeneous group of hereditary disorders characterized by abnormalities in structures of ectodermal origin. Incontinentia pigmenti (IP) is an ED characterized by skin lesions evolving over time, as well as dental, nail, and ocular abnormalities. Due to X-linked dominant inheritance IP symptoms can only be seen in female individuals while affected males die during development in utero. We observed a family of horses, in which several mares developed signs of a skin disorder reminiscent of human IP. Cutaneous manifestations in affected horses included the development of pruritic, exudative lesions soon after birth. These developed into wart-like lesions and areas of alopecia with occasional wooly hair re-growth. Affected horses also had streaks of darker and lighter coat coloration from birth. The observation that only females were affected together with a high number of spontaneous abortions suggested an X-linked dominant mechanism of transmission. Using next generation sequencing we sequenced the whole genome of one affected mare. We analyzed the sequence data for non-synonymous variants in candidate genes and found a heterozygous nonsense variant in the X-chromosomal IKBKG gene (c.184C>T; p.Arg62*). Mutations in IKBKG were previously reported to cause IP in humans and the homologous p.Arg62* variant has already been observed in a human IP patient. The comparative data thus strongly suggest that this is also the causative variant for the observed IP in horses. To our knowledge this is the first large animal model for IP.

Expression of Foxi3 is regulated by ectodysplasin in skin appendage placodes

BACKGROUND Foxi3 is a member of the large forkhead box family of transcriptional regulators, which have a wide range of biological activities including manifold developmental processes. Heterozygous mutation in Foxi3 was identified in several hairless dog breeds characterized by sparse fur coat and missing teeth. A related phenotype called hypohidrotic ectodermal dysplasia (HED) is caused by mutations in the ectodysplasin (Eda) pathway genes. RESULTS Expression of Foxi3 was strictly confined to the epithelium in developing ectodermal appendages in mouse embryos, but no expression was detected in the epidermis. Foxi3 was expressed in teeth and hair follicles throughout embryogenesis, but in mammary glands only during the earliest stages of development. Foxi3 expression was decreased and increased in Eda loss- and gain-of-function embryos, respectively, and was highly induced by Eda protein in embryonic skin explants. Also activin A treatment up-regulated Foxi3 mRNA levels in vitro. CONCLUSIONS Eda and activin A were identified as upstream regulators of Foxi3. Foxi3 is a likely transcriptional target of Eda in ectodermal appendage placodes suggesting that HED phenotype may in part be produced by compromised Foxi3 activity. In addition to hair and teeth, Foxi3 may have a role in nail, eye, and mammary, sweat, and salivary gland development.

[Diseases of the nails].

Nail alterations are frequently seen in daily practice, but they are often difficult to interpret. Basic knowledge of the anatomy and biology of the nail facilitates their diagnosis as this frequently allows their development and morphology to be explained. The following short review gives hints at the most important infections, inflammatory nail diseases and tumors.

Lack of fifth anchoring point and violation of the insertion of the rotator cuff during antegrade humeral nailing: pitfalls in straight antegrade humeral nailing.

Antegrade nailing of proximal humeral fractures using a straight nail can damage the bony insertion of the supraspinatus tendon and may lead to varus failure of the construct. In order to establish the ideal anatomical landmarks for insertion of the nail and their clinical relevance we analysed CT scans of bilateral proximal humeri in 200 patients (mean age 45.1 years (sd 19.6; 18 to 97) without humeral fractures. The entry point of the nail was defined by the point of intersection of the anteroposterior and lateral vertical axes with the cortex of the humeral head. The critical point was defined as the intersection of the sagittal axis with the medial limit of the insertion of the supraspinatus tendon on the greater tuberosity. The region of interest, i.e. the biggest entry hole that would not encroach on the insertion of the supraspinatus tendon, was calculated setting a 3 mm minimal distance from the critical point. This identified that 38.5% of the humeral heads were categorised as 'critical types', due to morphology in which the predicted offset of the entry point would encroach on the insertion of the supraspinatus tendon that may damage the tendon and reduce the stability of fixation. We therefore emphasise the need for 'fastidious' pre-operative planning to minimise this risk.

Fractures in Children and Adolescents

Fractures of the growing bone require fixation techniques, which preclude any injury to the growth plate regions. This requirement is met by Elastic Stable Intramedullary Nails (ESIN) which are positioned between both metaphyseal regions. Pronounced malposition and/or shortening, open fractures and fractures with impending skin perforation are indications for clavicle nailing in adolescents. Retrograde nailing with two elastic nails, inserted from lateral, is the method of choice for stabilization of humerus fractures. In radial neck fractures with severe tilting of the radial head, a retrograde nail may reduce and fix the head. In Monteggia lesions, the ulna fracture is reduced and fixed with an antegrade nail. Forearm fractures with unacceptable axial deviation are reduced and fixed with one antegrade nail in the ulna and a retrograde nail in the radius. Ascending elastic nailing is done for femur shaft and proximal femur fractures. The medial and lateral entry sites are located above the distal physis. End caps are used to prevent shortening in spiral and multiple segment fractures. Fractures of the distal third of the femur are nailed in a descending technique. The entry sites of two nails are located on the lateral cortex below the greater trochanter. Combined tibia and fibula fractures, open fractures and unstable fracture types such as spiral and multifragmental tibia fractures are good indications for ESIN. Descending nailing is the method of choice. The nail entry points are medially and laterally distal to the apophysis of the proximal tibia. Thorough knowledge of each fracture type, fracture location and age specific healing pattern is necessary for safe and effective treatment of pediatric fractures