Laura F. Sandoval

Electrosurgery: Part I. Basics and principles

The term electrosurgery (also called radiofrequency surgery) refers to the passage of high-frequency alternating electrical current through the tissue in order to achieve a specific surgical effect. Although the mechanism behind electrosurgery is not completely understood, heat production and thermal tissue damage is responsible for at least the majority--if not all--of the tissue effects in electrosurgery. Adjacent to the active electrode, tissue resistance to the passage of current converts electrical energy to heat. The only variable that determines the final tissue effects of a current is the depth and the rate at which heat is produced. Electrocoagulation occurs when tissue is heated below the boiling point and undergoes thermal denaturation. An additional slow increase in temperature leads to vaporization of the water content in the coagulated tissue and tissue drying, a process called desiccation. A sudden increase in tissue temperature above the boiling point causes rapid explosive vaporization of the water content in the tissue adjacent to the electrode, which leads to tissue fragmentation and cutting.

Systemic Therapies for Psoriasis: An Evidence-Based Update

BackgroundThe treatment of psoriasis has evolved over the years, with the focus now largely on the use of biologic agents. With treatment options expanding, evidence-based studies to guide physicians’ treatment decisions become increasingly important.ObjectiveOur objective was to review current literature to provide an evidence-based update on systemic therapies for psoriasis.MethodsA systematic review of the literature was conducted from 1 January 2012 through 1 July 2013 to identify all randomized clinical trials and systematic reviews of systemic psoriasis treatments.ResultsA total of 46 publications were identified and reviewed. Randomized clinical trials for the treatment of psoriasis focused heavily on biologic agents, both currently approved agents and anti-interleukin (IL)-17 agents in development. The anti-IL-17 agents appear effective according to phase II clinical trials. Several new oral agents are being studied, and, although they do not appear as effective as the biologic agents, they may be an option as an alternative to traditional oral agents, with more favorable safety profiles. Several systematic reviews focused on efficacy among the biologics, with infliximab consistently superior to the others, and etanercept the least effective of the tumor necrosis factor-alpha inhibitors. Longer-term safety data on biologics is now available and encouraging.LimitationsCurrent studies of traditional oral therapies are lacking.ConclusionsCurrent studies continue to support the use of biologic agents in the treatment of moderate to severe psoriasis, with better efficacy and safety profiles than traditional systemic agents. Newer anti-IL-17 agents and several new oral agents are in development and have shown promise in clinical trials.

Long-term adherence to topical psoriasis treatment can be abysmal: a 1-year randomized intervention study using objective electronic adherence monitoring

Most people with psoriasis have limited disease that could be treated with topicals, but topical efficacy is limited by low short‐term adherence. Psoriasis is a chronic disease, and long‐term adherence is an even bigger problem.

Entrance and propagation pattern of high-frequency electrical currents in biological tissues as applied to fractional skin rejuvenation using penetrating electrodes.

Fractional resurfacing of the skin using radiofrequency devices has been used for collagen remodeling and rejuvenation.

Electrosurgery: part II. Technology, applications, and safety of electrosurgical devices.

Electrosurgical currents can be delivered to tissue in monopolar or bipolar and monoterminal or biterminal modes, with the primary difference between these modes being their safety profiles. A monopolar electrosurgical circuit includes an active electrode and a dispersive (return) electrode, while there are 2 active electrodes in bipolar mode. In monoterminal mode, there is an active electrode, but there is no dispersive electrode connected to the patients body and instead the earth acts as the return electrode. Biterminal mode uses a dispersive electrode connected to the patients body, has a higher maximum power, and can be safer than monoterminal mode in certain situations. Electrosurgical units have different technologies for controlling the output power and for providing safety. A thorough understanding of these technologies helps with a better selection of the appropriate surgical generator and modes.

Measure of Atopic Dermatitis Disease Severity Using Actigraphy

Background: Analyzing adherence to treatment and outcomes in atopic dermatitis is limited by methods to assess continual disease severity. Atopic dermatitis significantly impacts sleep quality, and monitoring sleep through actigraphy may capture disease burden. Purpose: To assess if actigraphy monitors provide continuous measures of atopic dermatitis disease severity and to preliminarily evaluate the impact of a short-course, high-potency topical corticosteroid regimen on sleep quality. Methods: Ten patients with mild to moderate atopic dermatitis applied topical fluocinonide 0.1% cream twice daily for 5 days. Sleep data were captured over 14 days using wrist actigraphy monitors. Investigator Global Assessment (IGA) and secondary measures of disease severity were recorded. Changes in quantity of in-bed time sleep were estimated with random effects models. Results: The mean daily in-bed time, total sleep time, and wake after sleep onset (WASO) were 543.7 minutes (SEM 9.4), 466.0 minutes (SEM 7.7), and 75.0 minutes (SEM 3.4), respectively. WASO, a marker of disrupted sleep, correlated with baseline (ρ = .75) and end of treatment IGA (ρ = .70). Most patients did not have marked changes in sleep. IGA scores declined by a median change of 1 point at days 7 (p = .02) and 14 (p = .008). Conclusions: Using actigraphy, atopic dermatitis disease severity positively correlated with sleep disturbances. Actigraphy monitors were well tolerated by this cohort of atopic dermatitis subjects.

What's new in the topical treatment of allergic skin diseases

Purpose of reviewTo review recent literature on the topical treatment of allergic skin diseases to help clinicians make informed evidence-based decisions. Recent findingsTwenty-four publications were identified from a PubMed search of randomized controlled trials and systematic reviews of topical treatment of atopic dermatitis and allergic contact dermatitis published from 1 January 2013 to 31 January 2014. Studies on the topical treatment of atopic dermatitis largely supported the recommended use of topical corticosteroids and topical calcineurin inhibitors. Barrier therapy continues to play an important role without evidence supporting use of one emollient over another. Lipoxin A4, an eicosanoid with anti-inflammatory properties, and a 5% cis-urocanic acid emulsion cream were effective in the treatment of atopic dermatitis, although studies were small. Adjunct therapy with bleach baths, natural oils, and textiles all showed some benefit; however, studies are limited. Literature on topical treatment of allergic contact dermatitis was limited to one publication, providing evidence for a natural multicomponent cream as maintenance therapy after control of disease with a topical corticosteroid. SummaryThere is strong evidence for the use of topical anti-inflammatory therapies in the treatment of atopic dermatitis. There is little evidence to suggest that one emollient is better than others.

Are wash outs needed in clinical trials of topical agents

The Journal of Dermatological Treatment attracts reports of many clinical trials. Well-designed clinical trials often include a ‘wash out’ period, a requirement that patients discontinue their previous treatment for a period of time before they begin the study treatments. For example, psoriasis or atopic dermatitis studies might include a wash out of 1 or 2 weeks for topical treatments, a month for phototherapy or oral agents, or even longer wash out periods if the patient has been on a biologic medication. We like to think that these wash out periods are not necessary, particularly for topical treatments. When developing an investigator-initiated clinical trial, we try not to include a wash out period. One reason to not include a wash out period is that in clinical practice, we do not require patients to wait weeks or months after stopping a treatment to start a new treatment. On the contrary, we might even overlap a new treatment with an existing treatment in order to get control of the disease before recommending them to stop their earlier treatment. Studies that do not have wash out periods will, therefore, be more informative about what to expect in clinical practice. But we have a strong aversion to wash out periods for topical treatments, because we believe that patients probably are not taking the previously recommended topical treatment anyway. Consider atopic dermatitis, for example. If we take a patient with total body, severe, lichenified atopic dermatitis, resistant to all topical and systemic treatment, admit them to the hospital and treat them with topical triamcinolone, they clear up in just 2–3 days. If a patient considering entering a trial is not getting better with the previously recommended topical treatment, it is likely that they are not using it. Objective studies ofpatients’ adherence to topical treatment confirm very poor use of topical medications, especially in the treatment of chronic skin diseases such as psoriasis, in which reported adherence rates are between 22 and 67% (1). If patients are not clearing up, it is likely they are not using the topical treatment. And if they are already off the treatment to the point it is not working, then requiring a wash out period just seems like unnecessary overkill, a needless barrier to study recruitment, on top of being inconsistent with how medical care is actually practiced in the clinic setting. While we expect that trials for registration will continue to include wash outs for most trials, we will look on them in a bemused way.

Emerging treatment options for psoriasis

License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Psoriasis: Targets and Therapy 2014:4 27–35 Psoriasis: Targets and Therapy Dovepress

Improved psoriasis with weight loss: the role of behavioural factors.

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