Fat transfer: current use in practice

The author has used fat transfer, including pearl fat grafts and fat injections, for almost 18 years in practice. Techniques for pearl fat grafting and fat injections are described. Pearls are limited to eyelids and small depressions. Fat injections can be used to augment various facial areas, including chin, cheekbones, nasolabial folds, lips, labiomandibular folds, glabella, forehead, and nose.

Liquid injectable silicone: techniques for soft tissue augmentation

This article includes a description of the uses and indications of liquid injectable silicone and a discussion of the results obtained. Patient selection, indications, mechanism of action, potential complications, and adjunct procedures are also addressed.

Ca2+ oscillations in response to methamphetamine in dopamine neurons of the ventral tegmental area in rats subchronically treated with this drug

Mesolimbic dopamine neurons in the ventral tegmental area (VTA), which project to the nucleus accumbens and prefrontal cortex, play an important role in the regulation of emotion, rewarding, and cognition. The dopamine neurons in the VTA have also been implicated in schizophrenia and drug abuse. Methamphetamine (METH) can induce a schizophrenia-like psychosis. Thus, the VTA is a likely effector site for the action of METH. However, effects of METH on the mesolimbic dopamine neurons are largely unknown. We treated adult SD rats with METH (5 mg/kg/day) or saline for 7 days, isolated single VTA neurons from these treated rats, and monitored the neuronal activities by measuring cytosolic Ca2+ concentration ([Ca2+]i), which was followed by immunocytochemical identification of dopamine neurons. Acute administration of METH under superfusion conditions concentration-dependently increased [Ca2+]i in VTA dopamine neurons isolated from METH- and saline-treated rats. Furthermore, acutely administered METH induced oscillations of [Ca2+]i only in the dopamine neurons of the METH-treated group. The METH-induced [Ca2+]i oscillations were inhibited by Ca2+-free conditions and by Ca2+ channel blockers. In conclusion, subchronic METH treatment sensitizes VTA dopamine neurons to this drug, resulting in induction of [Ca2+]i oscillations. This sensitization of VTA dopamine neurons may account, at least in part, for the psycho-stimulant effects of METH, such as the dependence on and sensitization to METH.

The influence of a single ethanol injection on normal thyroid tissue of the rat

Macro- and microscopic changes in the normal thyroid gland of rats, and in the surrounding tissues 2 and 4 weeks after a single intrathyroidal ethanol injection (IEI), together with the influence of such treatment on the function of the recurrent laryngeal nerves and of the parathyroid glands, were assessed. The intraoperative macroscopic evaluation at 2 weeks (20 rats) and 4 weeks (20 rats) after IEI revealed the presence of a scar at the site of the IEI-treated lobe in seven (35%) and six (30%) rats, respectively, and the reduction of lobe dimensions in thirteen (65%) and fourteen (70%) rats, respectively. The microscopic evaluation of the lobe after IEI showed coagulative necrosis, reduction in thyroid follicle volume, disturbance of follicle structure, haemorrhage, haemosiderin deposits, inflammatory infiltration and fibrosis. No microscopic changes were observed in the tissues surrounding the thyroid, nor in the parathyroid glands located extrathyroidally or in the second thyroid lobe. No vocal cord dysfunction or significant changes in serum calcium levels after IEI were detected.

Subcutaneous hydration by hypodermoclysis. A practical and low cost treatment for elderly patients

As the world's population ages, chronic and degenerative diseases are rising. This scenario demands the development of new treatment techniques with lower costs, which are as efficient as the existing ones. Hypodermoclysis is the infusion of fluids into the subcutaneous tissue with a butterfly needle. This technique may be used for isotonic fluid replacement and to administer cytosine arabinoside, clodronate, antibiotics and narcotic analgesics. This review evaluates the evidence supporting the use of hypodermoclysis to treat elderly patients with dehydration and patients with terminal cancer, and discusses its indications, adverse effects and perspectives. A MEDLINE search of the last 30 years was done to recover all available literature. Hypodermoclysis therapy is a safe and effective method to provide fluids and narcotic analgesic therapy in elderly patients that are mild and moderate dehydrated and in patients with cancer. It seems a good option to provide antibiotics, but there is a need for more studies to evaluate this indication.

Insulin administration

The injection of insulin is essential for management of patients with type 1 diabetes and may be needed by patients with type 2 diabetes for intermittent or continuous glycemic control. The species and dosage of insulin used should be consistent, and the patient's injection technique should be reviewed periodically with the diabetes-care team. The effective use of insulin to obtain the best metabolic control requires an understanding of the duration of action of the various types of insulin and the relationship of blood glucose levels to exercise, food intake, intercurrent illness, certain medications, and stress; SMBG; and learning to adjust insulin dosage to achieve the individualized target goals established between the patient, family, and diabetes-care team.

[Subcutaneous perfusion of hypodermoclysis: a useful rehydration method in geriatrics]

A USEFUL TECHNIQUE IN GERIATRICS: Older people are at high risk of dehydration. In common practice, oral intakes are often inadequate. Intravenous infusion may be difficult and may generate complications. Hypodermoclysis or subcutaneous infusion is a useful technique for the prevention or cure of moderate dehydration in the older subjects. MANY ADVANTAGES AND FEW RISKS: When it is used correctly (i.e. volume and type of solutions, aseptic conditions) and when its contraindications are respected (i.e. emergency situations), hypodermoclysis is a simple technique that is safe, effective and comfortable. It does not need intensive surveillance and can be used both at home or in an institution, thus avoiding hospitalization of older subjects. A TECHNIQUE THAT SHOULD BE DEVELOPED: The numerous advantages of hypodermoclysis in older patients should encourage its wider use in geriatrics.

Does tumescent infiltration have a deleterious effect on undermined skin flaps?

In summary, we think that the intradermal injection of the tumescent solution with epinephrine, which produced a peau d'orange appearance of the overlying skin, resulted in superficial flap loss secondary to the vasoconstrictive property of epinephrine combined with the hydrostatic pressure of the injection in this patient within a superficial plane and flap elevation. This delayed the clearance of epinephrine from the flaps. In this case, removal of the sutures did not result in any improvement in the flap, and this maneuver was performed too late. If a peau d'orange appearance is observed after injection, we recommend waiting until the fluid has time to recirculate (15 to 30 minutes, at a minimum) and avoid immediate incising or undermining of the flap.

[Subcutaneous drug administration. Indications for the use in terminal patients]

The preferred methods to administer medicines to the sick are oral, under the tongue, or rectal; but in the case of the terminally ill patient, we may encounter the problem that the drugs which they tend to require do not come in either of these preferred administering methods since these patients symptoms and problems demand complex responses. In these cases, the subcutaneous way winds up being highly recommended; therefore, the authors present the pharmacological bases of this method, they describe continuous subcutaneous perfusion, and all those aspects of this method which might be interesting to the professionals who employ it.

Insulin delivery using pen devices. Simple-to-use tools may help young and old alike

Results of landmark studies such as the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study are encouraging patients with diabetes and health professionals alike to strive to achieve and maintain the best possible glucose control. Insulin pens have the potential to become a major asset for improving compliance among diabetic patients. These devices offer substantial improvements in convenience, freedom, and flexibility for all insulin-using patients. Furthermore, more accurate dosing associated with use of the pen may hold the key to better longterm outcomes.

Intermittent subcutaneous injections of pain medication: effectiveness, manageability, and satisfaction

This study describes the use of intermittent subcutaneous injections of medications for pain control in a home hospice program. Six questionnaires were used to collect data over a one-year time period on the 52 patients who received medications by this route. Eighty-four percent of those patients had a diagnosis of cancer; patients received hospice care for a mean of 25 days. On average, intermittent subcutaneous medications were instituted three days prior to the patient's death. The main indication for this route was difficulty swallowing. Morphine was the most frequently used drug; side effects from the medication and problems with the route were rarely reported. Demographic information was collected on both the nursing staff and patients' caregivers; analysis indicated that caregivers were able to manage the injections and were satisfied with the method. Assessment of pain prior to and following the injections demonstrated the effectiveness of this method in controlling patients' pain.

Subcutaneous fluid administration--better than the intravenous approach?

Hypodermoclysis is a method of subcutaneous fluid administration particularly useful in elderly patients and in palliative care settings where intravenous access may be difficult. Subcutaneous fluid delivery is an effective method of rehydration and of opioid administration, and can prevent the need for intravenous catheterization and consequently hospitalization. It is a simple procedure to initiate, safe, less distressing to the patient, and does not predispose to intravascular related infections. The reported incidence of infection at the delivery site is extremely low. However, local guidelines should be agreed so that a standardized protocol is operated and risks of localized infection are minimized.

The tumescent technique: the effect of high tissue pressure and dilute epinephrine on absorption of lidocaine

Injection of lidocaine into the subcutaneous tissues by the tumescent technique results in a delayed absorption of the local anesthetic and has allowed clinicians to exceed the maximum recommended dose of lidocaine without reported complications. However, little knowledge exists about the mechanisms that permit such high doses of lidocaine to be used safely with this technique. The presence of low concentration epinephrine and the increased tissue pressure resulting from the tumescent injection have both been implicated as important factors, but neither has been studied in patients whose results were not altered by the variability of the suction procedure. The purpose of this work was to determine the effect of tissue pressure during tumescent injection and presence of low concentration epinephrine on the absorption of lidocaine from subcutaneous tissues in human volunteers. Twenty healthy female human volunteers were randomized into four study groups. After body fat measurements, all subjects received an injection of 7 mg/kg of lidocaine into the subcutaneous tissues of both lateral thighs. The injected solution consisted of 0.1% lidocaine and 12.5 meq/liter sodium bicarbonate in normal saline with or without 1:1,000,000 epinephrine. Tissue pressure was recorded during injection using a specially designed double-barreled needle. The time required for injection was also recorded. Subjects in group 1 received lidocaine with epinephrine injected by a high-pressure technique. Group 2 subjects received lidocaine with epinephrine injected by a low-pressure technique. Group 3 subjects received lidocaine without epinephrine injected under high pressure. Group 4 subjects received lidocaine without epinephrine injected under low pressure. Following injection, sequential blood samples were drawn over a 14-hour period, and plasma lidocaine concentrations were determined by gas chromatography. No suction lipectomy was performed. Maximum tissue pressure during injection was 339 +/- 63 mmHg and 27 +/- 9 mmHg using high- and low-pressure techniques, respectively. Addition of 1:1,000,000 epinephrine, regardless of the pressure of injected fluid, significantly delayed the time to peak plasma concentration by over 7 hours. There was no significant difference in the peak plasma concentration of lidocaine among the four groups. Peak plasma concentrations greater than 1 mcg/ml were seen in 11 subjects. Epinephrine (1:1,000,000) significantly delays the absorption of lidocaine administered by the tumescent technique. High pressure generated in the subcutaneous tissues during injection of the solution does not affect lidocaine absorption. The delay in absorption may allow time for some lidocaine to be removed from the tissues by suction lipectomy. In addition, the slow rise to peak lidocaine concentration in the epinephrine groups may allow the development of systemic tolerance to high lidocaine plasma levels.

[Treatment of severe uremic hyperparathyroidism using a method for percutaneous injection of the parathyroid glands with ethanol]

The results of recent studies suggest that uremic patients with large parathyroid hyperplasia are often resistant to active vitamin D3 therapy. Percutaneous ethanol injection has become an interesting option in such cases, although there are only a few publications on that subject. In this work we would like to present our experience with this method. 20 patients with serum iPTH > 400 pg/ml and 1-4 hyperplastic parathyroids (mean volume 1.07) underwent 56 percutaneous ethanol injection sessions under ultrasonographic guidance. In 9 patients a marked (> 75%), long-term (12-24 months) decrease in serum iPTH was achieved; lesser (> 50%) reduction in parathyroid activity persisted for 36-42 months in 5 out of 9 patients observed in this period. In almost every patient a significant reduction of alphacalcidol dose was possible. Our data confirm that percutaneous ethanol injection therapy is a useful and safe adjunct in severe uremic hyperparathyroidism treatment strategy which allows to restore the responsiveness to active vitamin D3 metabolites.

Accuracy of pen injectors versus insulin syringes in children with type 1 diabetes

OBJECTIVE

To compare the accuracy and precision of insulin syringes and pen devices used by children with type 1 diabetes and their parents.

RESEARCH DESIGN AND METHODS

There were 48 subjects (32 patients, a parent of an additional 16 patients) instructed to measure out morning insulin doses three times from vials and/or cartridges containing saline mixed with small amounts of [14C]glucose (solution used as regular insulin) and [3H]glucose (solution used as NPH insulin) and to dispense the contents into a scintillation vial. Statistical analysis was used to determine the accuracy and precision of both methods of insulin delivery.

RESULTS

The absolute error in measuring out doses of regular insulin < 5 U was greater with insulin syringes compared with pen injection devices (9.9 +/- 2.4 vs. 4.9 +/- 1.6%, respectively). Both were comparable for regular insulin doses > 5 U (3.2 +/- 0.6 vs. 2.2 +/- 0.4% for syringes and pens, respectively). The accuracy in drawing up NPH doses was similar for low and high insulin doses (mean percent error of 7.5 +/- 1.5 vs. 5.6 +/- 1.1%).

CONCLUSIONS

Pen devices are more accurate than insulin syringes in measuring out insulin at low insulin doses. The accuracy of insulin syringes improves when higher doses of regular insulin are measured out and becomes comparable to pen devices.