Absence of human papillomavirus DNA in the plume of erbium:YAG laser-treated warts

Virus and viral components transmitted through surgical smoke; a silent danger in operating room: a systematic review

BACKGROUND

During surgical procedures, heat-generating devices are widely used producing surgical smoke (SS). Since the SS can transmit infectious viruses, this systematic review was designed to investigate the potential viruses transmitted through SS.

METHODS

PubMed, Scopus, Web of Science, ProQuest, and Embase databases, along with Cochran Library, and Google Scholar search engine were searched systematically (by April 21, 2024). No language, place, and time restrictions were considered. All studies evaluating the SS and virus transmission, and whole investigations regarding the viral infections transmitted through SS were totally considered inclusion criteria. Besides, non-original, qualitative, case reports, case series, letters to the editor, editorial, and review studies were excluded from the analysis. This study was conducted in accordance with the PRISMA 2020 statement.

RESULTS

Twenty-six eligible studies were selected and reviewed for data extraction. The results showed that the SS contains virus and associated components. Six types of viruses or viral components were identified in SS including papillomavirus (HPV, BPV), Human Immunodeficiency Virus (HIV), varicella zoster, Hepatitis B (HBV), SARS-CoV-2, and Oral poliovirus (OPV), which are spread to surgical team through smoke-producing devices.

CONCLUSIONS

Since the studies confirm the presence of viruses, and viral components in SS, the potential risk to the healthcare workers, especially in operating room (OR), seems possible. Thus, the adoption of protective strategies against SS is critical. Despite the use of personal protective equipment (PPE), these viruses could affect OR personnel in surgical procedures.

COVID-19 infection risk by open and laparoscopic surgical smoke: A systematic review of the literature

BACKGROUND

The current COVID-19 pandemic has greatly changed the way surgery is delivered. In particular, current guidelines and policies have highlighted the need to use high level Personal Protective Equipment to reduce the risk of viral infection during open and laparoscopic surgical procedures. In particular, it was felt that the laparoscopic approach was at higher risk of viral transmission due to the chimney effect of the smoke escape from the trocars during and after the procedure. However, with this being a new and largely unknown viral agent, guidelines have been based on speculation and extrapolation from previous studies conducted in completely different situations, and led to anxiety amongst surgeons and theatre staff. We decided to conduct a systematic review of the Literature to try to clarify whether inhalation of surgical smoke can increase the risk of COVID-19 infection.

METHODS

A thorough search of the relevant Literature was performed following the PRISMA guidelines and the most relevant papers on this topic were selected for qualitative analysis. Duplicates, review, personal opinions and guidelines have been excluded. Quantitative analysis has not been performed due to the lack of homogeneous high-quality studies.

RESULTS

Literature search identified 740 papers but only 34 of them were suitable for qualitative analysis. The quality of those studies is generally quite low. We were not able to find any evidence directly linking surgical smoke with viral transmission, other than in patients with active HPV infection.

DISCUSSION

Inhalation of surgical smoke can be generally hazardous, and therefore the use of PPE during surgical operations must be recommended in any case. However, the present systematic review of the existent Literature did not identify any significant evidence of the risk of viral transmission with the surgical smoke, therefore the current guidelines restricting the use of laparoscopy and/or diathermy during the current Covid-19 pandemic may be considered excessive and non-evidence based.

A knowledge gap unmasked: viral transmission in surgical smoke: a systematic review

BACKGROUND

Concerns regarding the aerosolized transmission of SARS-CoV-2 via SS have caused significant apprehension among surgeons related to the use of minimally invasive surgery (MIS) during the COVID19 pandemic. While a limited number of studies have previously demonstrated the presence of viral material in SS, no comprehensive systematic review exists on the subject of viral transmission in SS. Methods A systematic review of the literature was conducted as per PRISMA guidelines. MEDLINE, EMBASE, and CENTRAL databases were searched for publications reporting the primary outcome of the presence of viral particles in SS and secondary outcomes of indices suggesting transmission of viable virus particles in SS producing clinically important infection. All human, animal, and in vitro studies which used accepted analytic techniques for viral detection were included. A meta-analysis was not complete due to methodologic heterogeneity and inconsistent reporting of outcomes of interest.

RESULTS

23 publications addressed the presence of viral components in SS, and 19 (83%) found the presence of viral particles in SS. 21 publications additionally studied the ability of SS to induce clinically relevant infection in host cells, with 9 (43%) demonstrating potential for viral transmission.

CONCLUSION

Evidence exists for viral transmission via SS. However, HPV remains the only virus with documented transmission to humans via SS. While meaningful translation into practical guidelines during the COVID pandemic remains challenging, no evidence exists to suggest increased risk in MIS.

Treatment of Recurrent Respiratory Papillomatosis: Case Series and Review of Technique

Adult Recurrent Respiratory Papillomatosis (RRP) is a rare disease caused by the human papilloma virus in which papilloma grows from the respiratory epithelium. Patients can suffer from significant respiratory distress secondary to tracheal or bronchial obstruction by papilloma and the mainstay of treatment is bronchoscopic debridement. There are a variety of techniques to resect the endoluminal tumor, including CO2 or YAG laser, argon plasma coagulation, microdebrider and cold forceps. There have been documented cases of healthcare workers contracting HPV after exposure to surgical smoke during ablation of papilloma and measures should be taken to avoid inhalation of the smoke plume. For proximal lesions that are accessible to a microdebrider, this appears to be a safe and effective technique that does not generate heat or surgical smoke. The rate of recurrence of adult-onset respiratory papilloma after initial debulking varies and adjuvant medical therapy including intralesional cidofovir, interferon, or oral indole-3-carbinol has been used to slow recurrence. Malignant transformation of adult-onset RRP to squamous cell carcinoma has been reported to occur in 3-7% of cases. Therefore, ongoing surveillance is needed to monitor for disease progression and malignant transformation. Here we describe three patients whose tracheal disease was managed with an Nd-YAG laser and microdebrider. One patient was treated with adjuvant systemic indole-3 carbinol and another was maintained with serial debridement only. The third patient presented with obstructing squamous cell carcinoma of the trachea and was treated with definitive chemoradiation. She presented with a new left mainstem lesion 6 months later which was diagnosed as RRP. She was started on indole-3 carbinol, but unfortunately it transformed to squamous cell carcinoma 8 months later.

Consistency of global recommendations regarding open versus laparoscopic surgery during the COVID-19 pandemic: a systematic review

Background

Throughout the COVID‐19 pandemic, there has been worldwide debate regarding whether open surgery should be performed in preference to laparoscopic surgery due to the theoretical higher risk of viral aerosolization by the release of pneumoperitoneum. We aimed to assess the consistency of national and international surgical society recommendations regarding the choice of surgical approach; assess the quality of evidence of viral emission in surgical aerosol; and assess the quality of evidence comparing aerosol generation by different surgical energy devices.

Methods

A systematic review of PubMed, Medline, Embase and Cochrane databases was performed. Three search strategies were employed. Twenty‐eight studies were included in the final analysis and quality appraised. Confidence in review findings was assessed using the GRADE‐CERQual (Confidence in Evidence from Reviews of Qualitative research) tool.

Results

Worldwide recommendations regarding open versus laparoscopic surgery are consistent, with a majority recommending that surgical approach is decided on a case‐by‐case, risk minimization approach. There is limited, low‐quality evidence that viral particles can be emitted in surgical aerosol. There is a paucity of literature on the quantity of aerosol produced by different surgical energy devices, and no evidence to support the use of certain surgical instruments to minimize aerosol production.

Conclusions

There is considerable consistency among worldwide recommendations regarding the choice of surgical approach, although the evidence base is lacking. To inform clinical recommendations, further research examining viral emission, transmission, infectivity and amount of surgical aerosol produced is required.

Occupational Skin Disease in Physicians: A Review of the Literature

OBJECTIVES

Occupational skin disease (OSD) arises from work-related activity. However, there is a paucity of literature on OSD in physicians. The aim of the this review was therefore to examine and summarize what types of symptomatic OSD physicians experience.

METHODS

We conducted a systematic literature search on Cochrane Library, Embase, and Pubmed.

RESULTS

Contact dermatitis from formaldehyde and glutaraldehyde were found in 11.5 and 13.5% of cases, respectively. In total 2.4-14.9% had latex allergy. The reported standardized incidence ratio of squamous cell carcinoma and melanoma was up to 2.15 [95% confidence interval (CI) 1.57-1.95] and 3.2 (95% CI 1.38-6.31). Transmission of human papilloma virus (HPV) particles during carbon dioxide laser wart ablation were found in 70% of samples collected from protective gloves and in 52% of samples from vapors.

CONCLUSIONS

The most frequently reported OSD in physicians is contact dermatitis from allergens in disinfectants and rubber gloves. There is also a risk of cutaneous reactions to latex. The incidence of skin cancer was higher in physicians than in the general population, and the reason for this remains unexplained and potentially biased. There are no reports of transmission of patient HPV to surgeons during wart ablation, possibly because of proper use of protective equipment.

Laser Plume From Human Papillomavirus-Infected Tissue: A Systematic Review

BACKGROUND

Laser procedures are becoming more prevalent across multiple medical specialties for a variety of indications. The plumes created by these lasers have raised concern for the dissemination of an infectious material.

OBJECTIVE

To review and summarize the information on viral dissemination in laser plumes available in the literature.

MATERIALS AND METHODS

Data Sources A systematic review was performed on English and non-English articles using the PubMed and the Cochrane databases. A manual search of bibliographies from relevant articles was also performed to collect additional studies.

STUDY SELECTION

Only articles in the English language with full texts available that pertained to viral particles in laser plumes were included. Data Extraction Two authors performed independent article selections using predefined inclusion and exclusion criteria.

RESULTS

There have been case reports of possible transmission of human papillomavirus (HPV) by inhalation of laser-produced aerosols. Multiple investigators have attempted to recreate this scenario in the laboratory to qualify this risk. Others have conducted clinical experiments to determine the presence of HPV in laser plumes.

CONCLUSION

The current body of the literature suggests that laser surgeons are at a risk for HPV exposure by inhalation of laser-derived aerosols. We offer best practice recommendations for laser operators.

Airborne human papillomavirus (HPV) transmission risk during ablation procedures: A systematic review and meta-analysis

BACKGROUND

Human Papillomavirus (HPV) is associated with development of oropharyngeal cancer. Aim of this review was to assess airborne transmission risk of infectious particles from HPV lesions to airway mucosa of medical staff during established ablation procedures.

METHODS

A systematic review of human and animal studies, published before 09/2020, relevant to airborne HPV transmission. Controlled studies reporting prevalence of HPV-associated upper airway (nasal/oral/pharyngeal) disease in staff performing ablation procedures (laser, loop electrosurgical excision [LEEP], cryosurgery) on HPV lesions were included in meta-analysis. Additionally, we aimed for a comprehensive systematic overview of studies regarding occupational risk of airborne HPV transmission and safety measures during ablation procedures.

RESULTS

A total of n = 30 original studies report outcomes related to HPV transmission risk in medical staff conducting ablation procedures. HPV DNA detection in ablation smoke (n = 7), matching HPV genotypes on ablated HPV lesions and face/airways of medical staff after ablation (n = 2), and evidence for infectivity of papillomavirus in ablation smoke (n = 3, animal models only) were reported. Three case reports describe occupational HPV disease of upper airway mucosa. Three controlled studies assessed warts (in CO₂ laser-users only); when pooling all controls (general population, non-laser users), nasal/oral/pharyngeal lesion sites were more common amongst laser-users (OR = 5.75; 95%CI[1.55, 21.38]; p < .001).

DISCUSSION

Airborne HPV dispersal with matching "high-risk" HPV-genotypes in airways of medical staff after ablations (LEEP and CO₂-laser) and cases of HPV-associated upper airways neoplasms based on exposure to laser and LEEP smoke are documented. Upper airway mucosa is a more common anatomical site for warts in CO₂ laser users compared to controls. Simple safety measures greatly reduce HPV contamination and transmission risk.

Dental Aerosol as a Hazard Risk for Dental Workers

Standard dental procedures, when using a water coolant and rotary instruments, generate aerosols with a significantly higher number of various dangerous pathogens (viruses, bacteria, and fungi). Reducing the amount of aerosols to a minimum is mandatory, especially during the new coronavirus disease, COVID-19. The study aimed to evaluate the amount of aerosol generated during standard dental procedures such as caries removal (using dental bur on a high and low-speed handpiece and Er:YAG laser), ultrasonic scaling, and tooth polishing (using silicon rubber on low-speed handpiece) combined with various suction systems. The airborne aerosols containing particles in a range of 0.3-10.0 μm were measured using the PC200 laser particle counter (Trotec GmbH, Schwerin, Germany) at three following sites, manikin, operator, and assistant mouth, respectively. The following suction systems were used to remove aerosols: saliva ejector, high volume evacuator, saliva ejector with extraoral vacuum, high volume evacuator with extraoral vacuum, Zirc® evacuator (Mr.Thirsty One-Step®), and two customized high volume evacuators (white and black). The study results showed that caries removal with a high-speed handpiece and saliva ejector generates the highest amount of spray particles at each measured site. The aerosol measurement at the manikin mouth showed the highest particle amount during caries removal with the low and high-speed handpiece. The results for the new high volume evacuator (black) and the Zirc® evacuator showed the lowest increase in aerosol level during caries removal with a high-speed handpiece. The Er:YAG laser used for caries removal produced the lowest aerosol amount at the manikin mouth level compared to conventional dental handpieces. Furthermore, ultrasonic scaling caused a minimal aerosol rise in terms of the caries removal with bur. The Er:YAG laser and the new wider high volume evacuators improved significantly suction efficiency during dental treatment. The use of new suction systems and the Er:YAG laser allows for the improvement of biological safety in the dental office, which is especially crucial during the COVID-19 pandemic.

Metagenomic analysis of the dust particles collected from the suction tube and the suction funnel of a dermatological laser smoke evacuator system

In the last few decades, there has essentially been an explosion in the use of lasers in medicine, especially in the area of cosmetic dermatology. Potentially harmful substances are liberated when tissues are vaporized with laser. This creates numerous risks, including the spread of infectious disease. Smoke evacuators are devices that capture and filter laser plume, thereby maintaining a safe environment for the surgical team and patient. Our aim was to characterize the microbial community structure within the suction tube and funnel of the smoke evacuator system, identify their origin, and evaluate pathogenicity. Dust particles were collected from the instruments with a cotton swab. DNA was extracted from the swabs and the transport media, and sequencing was performed using the Illumina HiSeq Xplatform. Metagenomic analysis was conducted using the Empowering the Development of Genomics Expertise (EDGE) Bioinformatics pipeline and custom Python scripts. The most abundant bacterial species were Micrococcus luteus and Brevibacterium casei in the suction tube, and Dermacoccus sp. Ellin 185 and Janibacter hoylei in the suction funnel. A total of 15 medium- to high-quality metagenome-assembled genomes (MAGs) were constructed where we found 104 antibiotic-resistant genes (ARGs) and 741 virulence factors. Findings indicate that the suction tube and funnel are likely a reservoir of virulence factor genes and ARGs, which can possibly be passed on to other bacteria via horizontal gene transfer. We would like to emphasize the health risk these microorganisms pose and the need to reevaluate the current hygiene standards with regard to the smoke evacuator system.

Risk of Virus Contamination Through Surgical Smoke During Minimally Invasive Surgery: A Systematic Review of the Literature on a Neglected Issue Revived in the COVID-19 Pandemic Era

CONTEXT

The coronavirus disease 2019 (COVID-19) pandemic raised concerns about the safety of laparoscopy due to the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diffusion in surgical smoke. Although no case of SARS-CoV-2 contagion related to surgical smoke has been reported, several international surgical societies recommended caution or even discouraged the use of a laparoscopic approach.

OBJECTIVE

To evaluate the risk of virus spread due to surgical smoke during surgical procedures.

EVIDENCE ACQUISITION

We searched PubMed and Scopus for eligible studies, including clinical and preclinical studies assessing the presence of any virus in the surgical smoke from any surgical procedure or experimental model.

EVIDENCE SYNTHESIS

We identified 24 studies. No study was found investigating SARS-CoV-2 or any other coronavirus. About other viruses, hepatitis B virus was identified in the surgical smoke collected during different laparoscopic surgeries (colorectal resections, gastrectomies, and hepatic wedge resections). Other clinical studies suggested a consistent risk of transmission for human papillomavirus (HPV) in the surgical treatments of HPV-related disease (mainly genital warts, laryngeal papillomas, or cutaneous lesions). Preclinical studies showed conflicting results, but HPV was shown to have a high risk of transmission.

CONCLUSIONS

Although all the available data come from different viruses, considering that the SARS-CoV-2 virus has been shown in blood and stools, the theoretical risk of virus diffusion through surgical smoke cannot be excluded. Specific clinical studies are needed to understand the effective presence of the virus in the surgical smoke of different surgical procedures and its concentration. Meanwhile, adoption of all the required protective strategies, including preoperative patient nasopharyngeal swab for COVID-19, seems mandatory.

PATIENT SUMMARY

In this systematic review, we looked at the risk of virus spread from surgical smoke exposure during surgery. Although no study was found investigating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or any other coronavirus, we found that the theoretical risk of virus diffusion through surgical smoke cannot be excluded.

Insights into laser safety considerations during COVID 19 pandemic

The World Health Organization has recently defined the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections as a pandemic. The infection, which may cause a potentially very severe respiratory disease, now called coronavirus disease 2019 (COVID-19), has airborne transmission via droplets while less attention focused on aerosol transmission. Surgical smoke and plumes in laser clinics represent a source for aerosol particles. The aim of this article is to provide the authors' opinion for the correct use of "laser devices" in the COVID-19 emergency and to reduce potential risks of laser airborne contaminants.

COVID-19 and Laparoscopic Surgery: Scoping Review of Current Literature and Local Expertise

BACKGROUND

The current coronavirus disease (COVID-19) pandemic is holding the world in its grip. Epidemiologists have shown that the mortality risks are higher when the health care system is subjected to pressure from COVID-19. It is therefore of great importance to maintain the health of health care providers and prevent contamination. An important group who will be required to treat patients with COVID-19 are health care providers during semiacute surgery. There are concerns that laparoscopic surgery increases the risk of contamination more than open surgery; therefore, balancing the safety of health care providers with the benefit of laparoscopic surgery for the patient is vital.

OBJECTIVE

We aimed to provide an overview of potential contamination routes and possible risks for health care providers; we also aimed to propose research questions based on current literature and expert opinions about performing laparoscopic surgery on patients with COVID-19.

METHODS

We performed a scoping review, adding five additional questions concerning possible contaminating routes. A systematic search was performed on the PubMed, CINAHL, and Embase databases, adding results from gray literature as well. The search not only included COVID-19 but was extended to virus contamination in general. We excluded society and professional association statements about COVID-19 if they did not add new insights to the available literature.

RESULTS

The initial search provided 2007 records, after which 267 full-text papers were considered. Finally, we used 84 papers, of which 14 discussed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Eight papers discussed the added value of performing intubation in a low-pressure operating room, mainly based on the SARS outbreak experience in 2003. Thirteen papers elaborated on the risks of intubation for health care providers and SARS-CoV-2, and 19 papers discussed this situation with other viruses. They conclude that there is significant evidence that intubation and extubation is a high-risk aerosol-producing procedure. No papers were found on the risk of SARS-CoV-2 and surgical smoke, although 25 papers did provide conflicting evidence on the infection risk of human papillomavirus, hepatitis B, polio, and rabies. No papers were found discussing tissue extraction or the deflation risk of the pneumoperitoneum after laparoscopic surgery.

CONCLUSIONS

There seems to be consensus in the literature that intubation and extubation are high-risk procedures for health care providers and that maximum protective equipment is needed. On the other hand, minimal evidence is available of the actual risk of contamination of health care providers during laparoscopy itself, nor of operating room pressure, surgical smoke, tissue extraction, or CO2 deflation. However, new studies are being published daily from current experiences, and society statements are continuously updated. There seems to be no reason to abandon laparoscopic surgery in favor of open surgery. However, the risks should not be underestimated, surgery should be performed on patients with COVID-19 only when necessary, and health care providers should use logic and common sense to protect themselves and others by performing surgery in a safe and protected environment.

It is time for a more cautious approach to surgical diathermy, especially in COVID-19 outbreak: A schematic review

Background

Many surgeons are unaware of the risks posed by the surgical diathermy. Apart from the numerous chemicals, surgical smoke had been shown to harbour intact bacterial and virus particles especially COVID-19 in the current time.

Objective

To identify the inhalational, infectious, chemical, and mutagenic risks of surgical smoke and suggest evidence-based hazard reduction strategies. Also to cogitate on the very high risk of viral spread by the use of surgical diathermy in COVID-19 outbreak.

Methods

A review of articles indexed for MEDLINE on PubMed using the keywords surgical smoke, diathermy, electrocautery, surgical smoke hazards, smoke evacuator, and guidelines for surgical smoke safety was performed. The review included evidences from 50 articles from the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature.

Results

There are risks associated with surgical smoke. Although some surgeons were aware, majority were not keen in the hazard reduction strategies.

Conclusion

Many chemical and biological particles have been found in surgical smoke. It is highly recommended to follow the standardised guidelines for surgical smoke safety. Surgical smoke carries full virus particle(such as COVID-19 virus), it is strongly recommended to minimise or avoid electrocautery during the COVID-19 outbreak.

Human papillomavirus and surgical smoke: a systematic review

Objective

To evaluate what is currently known about the risk to surgeons and other operating theatre (OT) staff of human papillomavirus (HPV) transmission and HPV-related disease following surgical smoke exposure.

Methods

A systematic literature search of Embase and Ovid-MEDLINE was undertaken for primary studies relevant to the presence of HPV in surgical smoke, contamination of OT staff with HPV after performing or attending smoke-generating surgical procedures, and the presence of HPV or HPV-related disease in OT staff following occupational surgical smoke exposure. Additional articles were identified by searching the reference lists of relevant published papers.

Results

Twenty-one relevant articles were identified. These demonstrate that surgical smoke from the treatment of HPV-related lesions can contain HPV DNA, and that this can contaminate the upper airways of OT staff. Whether this corresponds to infectious virus is not known. Increased prevalence of HPV infection or HPV-related disease in OT staff following occupational exposure to surgical smoke has not been convincingly shown.

Conclusions

While HPV transmission to OT staff from surgical smoke remains unproven, it would be safest to treat surgical smoke as potentially infectious. Necessary precautions should be taken when performing smoke-generating procedures, consisting of: (1) local exhaust ventilation, (2) general room ventilation and (3) full personal protective equipment including a fit tested particulate respirator of at least N95 grade. There is currently insufficient evidence to recommend HPV vaccination for OT staff or to state that the above precautions, when used properly, would not be effective at preventing HPV transmission from surgical smoke.

Occupational exposure of oropharyngeal human papillomavirus amongst otolaryngologists

OBJECTIVES/HYPOTHESIS

Human papillomavirus (HPV) is a DNA virus that causes cancer in multiple sites. Although sexual activity is the primary means of oropharyngeal HPV acquisition, studies suggest HPV transmission through occupational exposure from medical instruments and surgical fumes. We assess if aerosolization of HPV16 DNA via electrocautery places otolaryngologists at risk for exposure.

STUDY DESIGN

Animal and human laboratory model.

METHODS

Plasmid (pLXSN16E6E7) expressing HPV p16 E6/E7 genes was transformed into DH5α Escherichia coli cells using the heat shock method. Miniprep and maxiprep purification of transformed DNA with subsequent restriction enzyme double digestion confirmed presence of E6E7 fragment. We injected 2 μg plasmid DNA in 20 μL TE (Tris and ethylenediaminetetraacetic acid) buffer intradermally into freshly severed mouse tail then cauterized for 5 to 10 seconds. Generated fumes were collected through a suction tube fitted with Whatman filter paper. Filter paper was placed in 100 μL TE buffer. Additionally, six patients undergoing transoral robotic surgery for resection of oropharyngeal cancer were identified, three with p16-negative tumors and three with p16-positive tumors. Intraoperatively, Whatman filter paper was exposed to electrocautery fumes, then placed in 100 uL TE buffer. Additional samples were collected from the suction tubing and filter, the surgical mask of the surgeon at head of the bed, and the robot arm.

RESULTS

Samples were analyzed via polymerase chain reaction with an assay sensitivity of 1.5 ng E6E7 DNA. None of the patient or mouse tail samples yielded detectable HPV16 DNA in the electrocautery fumes. We did not detect HPV16 DNA on the surgical masks, suction apparatus, or robot arm intraoperatively.

CONCLUSIONS

There is likely minimal risk of occupational exposure to HPV16 via electrocautery fumes.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:2366-2371, 2020.

OR Air Quality: Is It Time to Consider Adjunctive Air Cleaning Technology?: 1.3 www.aornjournal.org/content/cme

Patients undergoing surgery may be at risk for infection from airborne particles such as dust, skin scales, respiratory aerosols, and hair fibers emanating from multiple sources in the OR, including personnel, heater-cooler devices, and surgical smoke. This risk is increased in surgical patients undergoing procedures involving implanted devices. Surgical personnel also are at risk from exposure to surgical smoke, which can contain viable viral particles including human papillomavirus infection. Air quality in the OR is improved by engineering controls (eg, maintaining positive pressure). During the past decade, innovations in the field of adjunctive technology designed to improve OR air quality include using ultraviolet disinfection and mobile ultraviolet disinfection plus high-efficiency particulate air filtration. Some of these technologies additionally provide continuous monitoring of circulating air particle counts. Additional research regarding the benefits of adjunctive air-cleaning technology in the OR is warranted.

Surgical smoke: Risk assessment and mitigation strategies

BACKGROUND

Although many dermatologic surgeons are aware of the risks of surgical smoke, many do not use hazard reduction strategies.

OBJECTIVE

To identify the infectious, inhalational, chemical, and mutagenic risks of surgical smoke in dermatologic procedures and suggest evidence-based hazard reduction strategies.

METHODS

A review of articles indexed for MEDLINE on PubMed using the keywords surgical smoke, dermatology, surgical mask, respirator, smoke evacuator, and guidelines in 13 combinations was performed by using Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols. The review included data from 45 articles from the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature.

RESULTS

There are risks associated with surgical smoke, and although some dermatologists are aware of these risks, many are not using hazard reduction strategies such as smoke evacuators and surgical masks.

LIMITATIONS

Most of the data regarding the hazards of surgical smoke and methods for smoke safety are derived from in vitro and in vivo studies in nonhumans, as well as from resources outside of the dermatology literature.

CONCLUSION

Standardized guidelines for surgical smoke safety should be implemented in the dermatology community and residency curriculum.

Long-Pulsed 532-Nm Neodymium-Doped Yttrium Aluminium Garnet Laser for Treatment of Facial Plane Warts in 160 Yemeni Patients

BACKGROUND

Warts in general and plane warts in particular pose a therapeutic challenge for dermatologists. Many treatment modalities exist, with variable success rates, side effect profiles, and precautions. The long-pulsed 532-nm neodymium-doped yttrium aluminium garnet (LP Nd:YAG) laser has not been previously used for this indication.

OBJECTIVE

This study was conducted to assess the efficacy and safety of the LP Nd:YAG laser for treating facial plane warts.

MATERIALS AND METHODS

A total of 160 Yemeni patients (62 women, 98 men; age range, 5-55 years) were exposed to 1 laser treatment session with the following parameters: wavelength, 532 nm; pulse duration, 20 millisecond; spot size, 2 to 3 mm; and fluence, 25 J/cm. The end point was graying or whitening of the lesion. Color photographs were taken before and immediately after treatment and at follow-up visits 1, 4, and 16 weeks after the laser session.

RESULTS

An overall clearance rate of 92% after only one session was achieved, with minimal and transient side effects.

CONCLUSION

The LP Nd:YAG laser is safe and effective for treating facial plane warts, with a success rate of 92% after only one session.

Novel Treatment Approach for Deep Palmoplantar Warts Using Long-Pulsed 1064-nm Nd:YAG Laser and a Moisturizing Cream Without Prior Paring of the Wart Surface

OBJECTIVE

The present study aimed to assess the safety and efficacy of palmoplantar wart removal using long-pulsed 1064-nm Nd:YAG laser after application of a moisturizing cream.

BACKGROUND

Previously described laser treatments for wart removal are associated with negative side effects and need to pare the warts before laser treatment.

PATIENTS/METHODS

Two hundred forty patients (142 males, 98 females) were treated for 1-40 palmoplantar warts by long-pulsed 1064-nm Nd:YAG laser (spot size 4-6 mm, pulse duration 20 msec, fluence 200 J/cm²) after covering the wart surface with a thin film of a moisturizing cream. The endpoint was lesion graying or whitening with or without development of a hemorrhagic bulla beneath the treated wart. Color photographs were taken before and immediately after each laser session and at 1, 4, and 16 weeks after the last session.

RESULTS

The overall clearance rate was 97%, with 90% of treated patients cured after one session, 4% after two, and 3% after three. Clearance rate after three laser sessions decreased linearly with the number of warts from 100% to 95%. Less accessible wart location in interdigital spaces also decreased the cure rate after three sessions from 100% to 95%. Additionally, warts became more difficult to eradicate as they aged. Remission lasted up to 6 years, and complications were mild and infrequent (17.5%).

CONCLUSIONS

This novel method is effective in removing palmoplantar warts. It is easier, time-saving, and safer than other methods described in previous studies conducted with ablative or nonablative lasers.

T* reatment of vulgar and plantar warts

The article presents data on clinical forms of warts associated with different types of human papillomavirus. The authors analyze the following wart treatment methods: excision, chemical and immune. Based on literature sources, the authors assess the efficacy, advantages and disadvantages of well-known treatment methods. The authors describe their own experience of treating primary and recurrent vulgar and plantar warts with an up-to-date chemical destruction drug - Mardil Zinc Max, a solution containing a complex compound of 1.5% zinc 2-chloropropionate in 2-chloropropionic acid. The efficacy of treatment of vulgar warts was 100%, and that of plantar ones - 62.5%. Clinical recovery was observed both in case of primary and recurrent processes. The treatment had no adverse effects or complications and was characterized by a low injury rate, good tolerance and full tissue recovery without any cosmetic defects.

Application of a two-zone model to estimate medical laser-generated particulate matter exposures

We estimated particulate matter exposures for two simulated medical laser procedures using a near-field/far-field model. Size-specific mass emission rates obtained from a laboratory-based emission chamber study were used with estimated room size, air exchange rate, and interflow between zones to demonstrate the potential exposure range. Modeled steady-state concentrations for the near-field ranged between 80 and 2140 μg/m(3) and between 40 and 1650 μg/m(3) in the far-field. Results indicate concentrations in the simulated scenarios are similar to those obtained from limited field assessments conducted in hospital operating rooms. Since new medical laser technologies and applications continue to grow, modeled occupational exposures of medical laser-generated particulate matter can be useful in better understanding these exposures in the clinical environment, and to inform control strategies.

Management of ungual warts

Warts are the most common nail tumor generally caused by human papilloma virus (HPV) 1, 2, 4, 27, and 57. HPV 16 and 18 are associated with malignant transformation to squamous cell carcinoma, while HPV 2 and 7 are associated with "butcher's warts." Current treatments range from topical and intralesional therapies to systemic agents and surgical procedures. Despite the numerous available possibilities for treatment, intralesional bleomycin appears to be the most effective treatment for periungual warts.

Is surgical smoke harmful to theater staff? a systematic review

BACKGROUND

Smoke is generated by energy-based surgical instruments. The airborne byproducts may have potential health implications. This study aimed to evaluate the properties of surgical smoke and the evidence for the harmful effects to the theater staff.

METHODS

Cochrane Database, MEDLINE, PubMed, Embase classic and Embase, and the metaRegister of Controlled Trials were searched for studies reporting the constituents found in the smoke plume created during surgical procedures, the methods used to analyze the smoke, the implications of exposure, and the type of surgical instrument that generated the smoke. Studies were excluded if they were animal based, preclinical experimental work, or opinion-based reports. The common end points were particle size and characteristics, infection risk, malignant spread, and mutagenesis.

RESULTS

The inclusion criteria were fulfilled by 20 studies. In terms of particle size, 5 (25%) of the 20 studies showed that diathermy and laser can produce ultrafine particles (UFP) that are respirable in size. With regard to particle characterization, 7 (35%) of the 20 studies demonstrated that a variety of volatile hydrocarbons are present in diathermy-, ultrasonic-, and laser-derived surgical smoke. These are potentially carcinogenic, but no evidence exists to support a cause-effect relationship for those exposed. In terms of infection risk, 6 (30%) of the 20 studies assessed surgical smoke for the presence of viruses, with only 1 study (5%) positively identifying viral DNA in laser-derived smoke. One study (5%) demonstrated bacterial cell culture (Staphylococcus aureus) from a laser plume after surgery. Regarding mutagenesis and malignant spread, one study (5%) reported the mutagenic effect of smoke, and one study (5%) showed the presence of malignant cells in the smoke of a patient undergoing procedures for carcinomatosis.

CONCLUSIONS

The potentially carcinogenic components of surgical smoke are sufficiently small to be respirable. Infective and malignant cells are found in the smoke plume, but the full risk of this to the theater staff is unproven. Future work could focus on the long-term consequences of smoke exposure.

Laser treatment of recurrent herpes labialis: a literature review

Recurrent herpes labialis is a worldwide life-long oral health problem that remains unsolved. It affects approximately one third of the world population and causes frequent pain and discomfort episodes, as well as social restriction due to its compromise of esthetic features. In addition, the available antiviral drugs have not been successful in completely eliminating the virus and its recurrence. Currently, different kinds of laser treatment and different protocols have been proposed for the management of recurrent herpes labialis. Therefore, the aim of the present article was to review the literature regarding the effects of laser irradiation on recurrent herpes labialis and to identify the indications and most successful clinical protocols. The literature was searched with the aim of identifying the effects on healing time, pain relief, duration of viral shedding, viral inactivation, and interval of recurrence. According to the literature, none of the laser treatment modalities is able to completely eliminate the virus and its recurrence. However, laser phototherapy appears to strongly decrease pain and the interval of recurrences without causing any side effects. Photodynamic therapy can be helpful in reducing viral titer in the vesicle phase, and high-power lasers may be useful to drain vesicles. The main advantages of the laser treatment appear to be the absence of side effects and drug interactions, which are especially helpful for older and immunocompromised patients. Although these results indicate a potential beneficial use for lasers in the management of recurrent herpes labialis, they are based on limited published clinical trials and case reports. The literature still lacks double-blind controlled clinical trials verifying these effects and such trials should be the focus of future research.

"Smoking guns": hazards generated by laser and electrocautery smoke

The smoke generated by laser surgery and electrocautery may contain significant amounts of toxic, carcinogenic, and infectious gases and particles. Although there is little scientific data on the actual type and extent of the hazards related to exposure, considering the potential for irreversible health damage, safety measures should not be delayed. All potentially exposed persons (including patients, medical, and cleaning staff) should be acquainted with the possible health and occupational hazards related to smoke from electrocautery and laser surgery procedures.

Transmission of human papillomavirus DNA from patient to surgical masks, gloves and oral mucosa of medical personnel during treatment of laryngeal papillomas and genital warts

The risk of occupational human papillomavirus (HPV) transmission from patient to medical personnel during laser vaporization procedures remains controversial. The purpose of this study was to determine the risk of HPV transmission from the patient to the protective surgical masks, gloves and oral mucosa of medical personnel during the treatment of laryngeal papillomas and genital warts. The study involved five male patients scheduled for the surgical treatment of laryngeal papillomas, and five male patients undergoing carbon dioxide (CO(2)) laser treatment for urethral warts. Oral mucosa specimens were obtained from the study patients and the employees pre- and postoperatively. Samples were collected from the HPV-infected patient tissue, and from the surgical masks and gloves used by the employees. A total of 120 samples were analyzed for the presence of HPV DNA by PCR, using the degenerated MY09/11/HMB01 primers. After the papilloma procedures, the surgeons' gloves tested HPV positive in one of the five cases and those of the surgical nurse in three of the five cases. After the treatment of genital warts, HPV DNA corresponding to the patient tissue specimens was present in all the samples obtained from the surgical gloves of the operators. All oral mucosa samples obtained from 18 different employees tested HPV negative, as did the surgical mask specimens. According to our study, HPV may contaminate protective equipment, most of all surgical gloves, but transmission of HPV DNA to medical personnel is unlikely to occur provided that protective surgical gloves and masks are applied and disposed of properly.

Laser-generated air contaminants from medical laser applications: a state-of-the-science review of exposure characterization, health effects, and control

The clinical use of lasers in surgery began in 1973 with applications of the carbon dioxide laser in otolaryngology, and since then the use of lasers has become commonplace in many medical and surgical specialties. Nonetheless, when biological tissue is subjected to laser radiation, the target cells can be vaporized, resulting in the aerosolization of their contents and the subsequent exposure of health care workers to laser-generated air contaminants (LGACs). The purpose of our analysis was to summarize and present all of the published literature pertaining to the laser-induced plume chemical and physical composition, health effects, and methods of control. The objective was to identify knowledge gaps within exposure science to set a research agenda for the protection of health care personnel exposed to LGACs. A literature search was performed using the PubMed database using a variety of search strategies and keyword combinations. To locate additional studies, we systematically searched the reference lists of all studies identified by our search, as well as key review papers. To date, researchers have identified roughly 150 chemical constituents of plume, as well as fine and ultrafine particulate matter, which has been shown to include viable cellular material, viruses, and bacteria. However, very few studies have attempted to characterize the effects of laser system type, power, and tissue treated, as it relates to LGAC exposure. Furthermore, current control strategies do not appear to be adequate in preventing occupational exposure to LGACs.

Lasers and radiofrequency devices in dentistry

Advances in technology are changing the ways that patients experience dental treatment. Technology helps to decrease treatment time and makes the treatment more comfortable for the patient. One technological advance is the use of lasers in dentistry. Lasers are providing more efficient, more comfortable, and more predictable outcomes for patients. Lasers are used in all aspects of dentistry, including operative, periodontal, endodontic, orthodontic, and oral and maxillofacial surgery. Lasers are used for soft and hard tissue procedures in the treatment of pathologic conditions and for esthetic procedures. This article discusses how lasers work and their application in the various specialties within dentistry.

Low risk of contamination with human papilloma virus during treatment of condylomata acuminata with multilayer argon plasma coagulation and CO₂ laser ablation

Multilayer argon plasma coagulation (APC) is a new effective method for the treatment of genital warts. We assessed the generation of aerosols containing human papilloma virus (HPV) DNA during treatment of genital warts with multilayer APC and with CO₂ laser ablation. Surveillance petri dishes, swabs from the glasses and nasolabial folds of the operating physician, and swabs taken from the suction units used during CO₂ laser ablation were tested by HPV PCR. HPV DNA corresponding to patient derived HPV types of genital warts was not found in any of the petri dishes and swabs obtained during APC treatment. HPV DNA was detected in none of the petri dishes obtained during CO₂ laser treatment, but in suction filters. In conclusion, both CO₂ laser ablation with plume suction and APC treatment seem to have a low risk of HPV contamination of the operation room.

Low- and high-intensity lasers in the treatment of herpes simplex virus 1 infection

Herpes simplex virus (HSV) is one of the most common viral infections of the human being. Although most of the seropositive persons do not manifest symptoms, infected individuals may present recurrent infections, characterized by cold sores. HSV-1 infection can result in potentially harmful complications in some patients, especially in those with compromised immunity. We report a clinical case of a patient with severe oral HSV-1 infection in the lower lip. The treatment of the lesions with the association of high-intensity (erbium-doped yttrium aluminum garnet, 2.94 mum, 80 mJ/pulse, 2-4 Hz) and low-intensity (indium gallium aluminum phosphide, 660 nm, 3.8 J/cm(2), 10 mW) lasers has not been reported in the literature. During treatment, no systemic or topical medication was used. Pain sensitivity was completely gone after the first irradiation with the low-intensity laser. During the healing process, lesions were traumatized twice, on the days 4 and 7. Even though the lesions were completely healed within 10 days.

COMPOSITION OF VOLATILE ORGANIC COMPOUNDS IN DIATHERMY PLUME AS DETECTED BY SELECTED ION FLOW TUBE MASS SPECTROMETRY

BACKGROUND

There is some evidence that surgical plume may pose a risk to health professionals, but the risks posed by volatile organic compounds have not been thoroughly investigated.

METHODS

The composition of volatile organic compounds in diathermy plume produced during surgery was analysed by selected ion flow tube mass spectrometry.

RESULTS

Hydrogen cyanide (3-51 parts per million), acetylene (2-8 parts per million), and 1,3-butadiene (0.15-0.69 parts per million) were identified in the plume.

CONCLUSION

Although there is no evidence of adverse health effects from the volatile organic compound in diathermy plume, the evidence that it is safe to breathe this plume is lacking. Therefore, we would recommend the use of smoke evacuators where practical.

An armamentarium of wart treatments

Patients and clinicians experience the frustration of cutaneous viral warts caused by infection with the human papilloma virus (HPV).Warts appear in various forms on different sites of the body and include common warts (verruca vulgaris), plane or flat warts, myrmecia, plantar warts, coalesced mosaic warts, filiform warts, periungual warts, anogenital warts (venereal or condyloma acuminata), oral warts and respiratory papillomas. Cervical infection with HPV is now known to cause cervical cancer if untreated. A review of the medical literature reveals a huge armamentarium of wart monotherapies and combination therapies. Official evidence-based guidelines exist for the treatment of warts, but very few of the reported treatments have been tested by rigorous blinded, randomized controlled trials.Therefore, official recommendations do not often include treatments with reportedly high success rates, but they should not be ignored when considering treatment options. It is the purpose of this review to provide a comprehensive overview of the wart treatment literature to expand awareness of the options available to practitioners faced with patients presenting with problematic warts.

Er:YAG Laser Ablation of Plantar Verrucae with Red LED Therapy–Assisted Healing

OBJECTIVE

The aim of this study was to evaluate Er:YAG ablation of plantar verrucae with red light-emitting diode (LED) therapy to assist healing.

BACKGROUND DATA

Successful removal of troublesome plantar verrucae still presents problems, particularly regarding complete removal and pain both postoperatively and during healing. A further problem is a high recurrence rate due to the aggressive viral dissemination associated with this kind of wart.

METHODS

Over 2 years, the author treated 121 plantar warts under local anesthesia in 58 patients with Er:YAG laser ablation followed by red LED therapy to assist wound healing. The Er:YAG laser (96 J/cm2, 2.0 J/pulse, 350 microsec pulsewidth, 2-mm collimated handpiece) is used first to ablate precisely the verrucous tissue until normal architecture is seen. Immediately after treatment, a red LED therapy system is applied (633 nm, 20 min, 96 J/cm2) to the wound and surrounding area. LED therapy at the same parameters is repeated on postoperative days 2, 6, and 10. A representative plantar verruca case is presented.

RESULTS

The Er:YAG laser precisely and cleanly ablates the plantar verrucae with clear margins into normal skin architecture, exhibiting minimal secondary thermal damage. After the first treatment session, patients are usually able to walk normally without any pain, even those who have bilateral verrucae, and no exudate is usually seen from postoperative day 2 on. By postoperative day 6, the wounds have shrunk noticeably and are filled with healthy granulation tissue, and by day 15 they are usually completely healed, with minimal scarring. At the 12-month follow-up, recurrence rates have been less than 6% (3/58 patients).

CONCLUSION

From the author's experience in 121 cases, the Er:YAG laser is ideally suited for precise and speedy ablation of plantar verrucae with minimal thermal damage to surrounding tissue, which, when coupled with visible red LED therapy, has given excellent, accelerated, and pain-free healing in these difficult-to-treat and slow-to-heal lesions with very low recurrence rates.

Infectious occupational exposures in dermatology--a review of risks and prevention measures. I. For all dermatologists

Dermatologists are at risk for exposure to infectious agents from a variety of sources throughout their workday. We review occupational infectious risks from percutaneous exposures, aerosolized infectious particles (eg, with laser surgery and dermabrasion), instrumentation, and cryotherapy. We also discuss current guidelines for management and postexposure prophylaxis of the more common occupational exposures, and conclude with an overview of means to minimize them.

Therapy of cutaneous human Papillomavirus infections

Human Papillomaviruses (HPV) are double-stranded DNA viruses, which result in a variety of clinical manifestations according to type. The most common cutaneous lesions include warts located on the skin and genitalia. Because there is currently no cure for HPV infection, treatment focuses on the alleviation of signs and symptoms. Unfortunately, therapy has not been proved to affect transmissibility. Traditional treatment modalities have focused on the destruction of infected tissue through a variety of techniques. These include podophyllin resin, podophyllotoxin, salicylic acid, trichloroacetic acid, bichloroacetic acid, cryotherapy, laser, and surgical techniques. None of these modalities have been proved to be superior. More recently, immunomodulatory compounds with antiviral properties have demonstrated superior efficacy with clearance rates up to 77% and low recurrence rates. Most importantly, clinical trials of vaccines to prevent acquisition of oncogenic HPV are demonstrating marked safety and efficacy.

Laser palliation of oral manifestations of human immunodeficiency virus infection

BACKGROUND

The author describes the use of lasers to palliate the oral manifestations of the human immunodeficiency virus, or HIV, infection. He discusses the advantages to both patients and dentists, but he does not address the use of lasers as a modality to treat or cure HIV infection.

CASE DESCRIPTION

Many oral manifestations of HIV infection can be used as markers for degree of immunosuppression. These manifestations may be treated with antibiotics, analgesics and antineoplastics, which may interact and interfere with antiviral agents used to treat the disease and possibly may exacerbate it. The author describes laser palliation of the oral manifestations of three HIV-positive patients.

CLINICAL IMPLICATIONS

Dentists will see more patients living longer with HIV as the disease becomes more treatable. Lasers have been shown to be effective instruments in palliation of oral manifestations of HIV infection.

Human papillomavirus: a review

Human papillomavirus infection remains a great source of morbidity and mortality. Progress in understanding the structure of HPV and its pathogenesis has led to a wide variety of possible new treatment modalities to combat HPV-related disease. Most HPV infections (whether high risk or low risk) resolve without any medical intervention. Persistent or progressive disease, however, remains difficult to treat. Although currently available therapies have proved efficacious and tolerable in the treatment of nongenital and genital warts, no single therapy is uniformly effective in eradicating persistent HPV infection. Cytodestructive methods, such as cryotherapy, remain the primary treatment modality for nongenital warts. Immune response modifiers, such as imiquimod, currently show the greatest promise in treating HPV-induced anogenital lesions, both with respect to complete response and in preventing recurrence. Human papillomavirus infection is one of the most common sexually transmitted diseases in the world, and cervical cancer still causes significant morbidity and mortality. Pap smear tests have greatly reduced the incidence and mortality of cervical cancer in developed countries. Additional research will focus on primary and secondary prevention strategies. Vaccines against high-risk HPV types are promising modalities currently under investigation to prevent HPV infections and possibly to treat them.

Treatment of common warts and actinic keratoses by Er:YAG laser

BACKGROUND AND OBJECTIVES

The use of ablative lasers in the treatment of common warts and precancerous actinic keratoses has been reported in the literature, showing variable response rates and relapse rates. The erbium:YAG laser (Er:YAG) with a wavelength of 2.94 microm allows precise ablation avoiding strong inflammation. The authors have evaluated the potential benefits of Er:YAG laser treatment for difficult-to-treat warts and actinic keratoses.

PATIENTS AND METHODS

A total of 69 patients with difficult-to-treat warts (periungual or plantar) with a mean age of 30.1 +/- 16.1 years (range 11-58 years), and 29 patients with actinic keratoses with a mean age of 73.5 +/- 9.7 years (range 58-90 years) were treated by Er:YAG laser. Ablative therapy was performed with a spot size of 3 mm, a frequency between 8 Hz and 15 Hz, and a fluence of 5.7-11.3 J cm(-2) (warts) or 5.7-7.1 J cm(-2) (actinic keratoses).

RESULTS

After a single laser treatment a complete response (CR) was observed in 50 patients with warts (72.5%). Plantar warts were more resistant (13.5% non-responder) compared with periungual warts (5.9% non-responder). Twelve patients with a CR showed a relapse within 3 months after treatment (24.0%). All but one suffered from plantar warts. Twenty-six patients with actinic keratoses showed a CR after a single laser treatment, and in three patients a partial response (PR) was achieved. None of the patients treated with Er:YAG laser developed pigment changes, wound infections or scarring.

CONCLUSION

Treatment of common epithelial lesions such as common warts or actinic keratoses by Er:YAG laser is safe and effective. In patients with plantar warts, however, a significant rate of relapse may occur, requiring additional therapy.

Principles of CO2/erbium laser safety

BACKGROUND

There are a variety of potential hazards with laser technology.

METHODS

A review of the literature.

OBJECTIVE

To summarize the potential hazards of CO2 and erbium laser technologies and the safety guidelines and equipment developed to minimize them.

RESULTS

Laser hazards can be divided into the following categories: mechanical, environmental, macrobiologic, microbiologic, and iatrogenic.

CONCLUSION

At the conclusion of this learning activity, the reader should be able to discuss the mechanical, environmental, macrobiologic, microbiologic, and iatrogenic hazards of resurfacing laser technology, the literature cited to support current safety guidelines, and the equipment developed to promote laser safety.