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Subcutaneous Fat Necrosis

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801. Thromboembolism (Treatment)

administration of warfarin sodium is started after anticoagulation with SC or IV anticoagulants has been achieved is because warfarin can have an initial procoagulant effect, particularly in patients with protein C or protein S deficiencies, potentially causing fat necrosis. For patients whose treatment has included thrombolysis for acute, massive PE causing hemodynamic instability, heparin infusion should be started once the thrombin time (TT) or aPTT is less than twice the baseline value. Treatment (...) been reported following UFH treatment of more than 1 month's duration. Skin necrosis Coumarin derivatives can cause skin necrosis as a consequence of widespread subcutaneous microthrombosis. This can occur in individuals who are protein C–deficient, either genetically or owing to large loading doses of a coumarin derivative. Areas usually affected include the breasts, abdominal wall, and lower extremities. [ ] Recurrence Recurrence of thromboembolism had been documented following discontinuance

2014 eMedicine Surgery

802. Plantar Fasciitis (Treatment)

the superficial layers of the subcutaneous tissue, because corticosteroid injection into the superficial fat pad can cause fat necrosis and atrophy, which reduce the shock-absorbing capacity of the plantar heel Studies have reported success rates of 70% or better. [ , ] Corticosteroid injections have been shown to improve symptoms at 1 month but not at 6 months. It is recommended not to give more than 3 steroid injections within a year. A randomized, controlled study demonstrated that intralesional (...) corticosteroids. [ ] Potential risks of corticosteroid injection include plantar fascia rupture, which was found in almost 10% of patients after plantar fascia injection in one case series, [ ] and fat pad atrophy. [ , ] Long-term sequelae were found in approximately 50% of patients with plantar fascia rupture. [ ] Improper placement of a corticosteroid injection for plantar fasciitis can result in necrosis and atrophy of the plantar fat pad at the heel. This complication may result in significant pain

2014 eMedicine Surgery

803. Morton Neuroma (Follow-up)

obtain either total resolution of symptoms or improvement to a satisfactory level with footwear modifications and restrictions. [ ] Corticosteroid or local anesthetic injections may be helpful, especially when coupled with the aforementioned shoe modifications. A dorsal injection is administered with 40 mg of methylprednisolone or a similar corticosteroid and 1% plain lidocaine or 0.5% plain bupivacaine in the same syringe. To avoid steroid-induced skin necrosis, do not inject into the superficial (...) subcutaneous tissue. Injections should not be used indiscriminately, because the injection itself is associated with mild risk. High-quality evidence supports the use of corticosteroid injections for short-term (3-month) symptom relief. [ , ] Symptom relief may last longer in smaller neuromas (<5 mm). [ ] Alcohol sclerosing injections should be used with caution, in that they have not been shown to be reliably effective. [ , , ] Nonsteroidal anti-inflammatory drugs (NSAIDs) or antiseizure medications

2014 eMedicine Surgery

804. Short-Bowel Syndrome (Follow-up)

mg/kg/day subcutaneously for 4 weeks, parenteral (0.16 g/kg/day) or enteral (30 g/day) glutamine supplementation, and a high-carbohydrate diet with 55-60% of calories coming from carbohydrates versus 20-25% from fat and 20% from protein. In 1997, Wilmore et al published their results on 87 patients treated with this regimen. [ ] After 4 weeks, 52% were completely off parenteral nutrition, and an additional 38% had significantly reduced parenteral nutrition requirements. The same investigators (...) of malnutrition and has been shown to benefit patient outcomes. TPN may be administered concurrently with enteral nutrition early in the clinical course of short-bowel syndrome because the ultimate goal in many of these patients is to enhance intestinal adaptation and render patients free of TPN as described by Wilmore et al in animal models. [ ] In many patients, intestinal adaptation, alone or in combination with modified and supplemented diets (eg, growth hormone, glutamine, high carbohydrate, low fat

2014 eMedicine Surgery

805. Salivary Gland Tumors, Major, Benign (Follow-up)

or reconstructed to afford the best chance of maintaining tone in the muscle or muscles being innervated. Another potential complication is sacrifice of the greater auricular nerve causing loss of sensation to the ear lobule and surrounding skin. To avoid this, careful dissection through the subcutaneous plane is performed to permit identification and preservation of the nerve as the anatomy allows. The facial hollowing and loss of facial symmetry that may result from tumor and gland removal can sometimes (...) be addressed at the time of surgery by placing cadaveric human dermal matrix or even by rotating a portion of the nearby sternocleidomastoid muscle into the deficit. Other approaches using avascular fat graft (harvested from the patient’s abdominal wall) have also been described. Postoperative gustatory sweating (Frey syndrome) is rare but may occur with aberrant reinnervation of the parasympathetics after parotid surgery. Use of thick skin flaps, placement of human dermal matrix, or both may mitigate

2014 eMedicine Surgery

806. Spinal Instability and Spinal Fusion Surgery (Follow-up)

beforehand. Thigh-high compression stockings (TED hose) and sequential compression devices are applied preoperatively for prophylaxis of deep vein thrombosis (DVT) and are not removed until the patient is mobilized postoperatively. In patients who are at particular risk for DVT and pulmonary embolism (PE; eg, those mwho are paraplegic, quadriplegic, or bedbound prior to surgery), subcutaneous injections of low-molecular-weight heparin (LMWH) may begin before the operation, with the individual patient's (...) exposures, care is taken to spare any neural structures that might correspond to a variant crossing of the recurrent laryngeal nerve. The prevertebral fascia is opened and the esophagus and pharynx are retracted toward the contralateral side. A transverse cervical artery, often accompanied by a vein, is usually identified over the C7 vertebral body in the superior extension of the mediastinal fat pad. This artery and the fat pad can usually be swept inferiorly and preserved. If exposed, this artery

2014 eMedicine Surgery

807. Xenotransplantation (Overview)

) and promote intravascular coagulation. After contact with human/primate blood, clots quickly develop in pECs. The increased clot formation may be immunologically mediated, or may be the result of specific hormone regulators. Lee et al. recently examined this question. [ ] Incubation of pECs with human tumor necrosis factor alpha (TNF-α) or interleukin-1α (IL-1α) caused an increase in porcine tissue factor (TF) activity and mRNA; however, those changes were not seen when these cells were exposed to 20 (...) . [ ] Adult pig islet cells were encapsulated in microcapsules implanted in the kidney or in a subcutaneous macrodevice in streptozocin-treated cynomolgus monkeys; in the latter group, diabetes was controlled for 6 months without immune suppression. This remarkable advance could pave the way for a variety of future human trials. The regulation of T-regulatory cells Still another approach involves inducing host immune tolerance and tissue accommodation; if the host immune system were ‘taught’ to tolerate

2014 eMedicine Pediatrics

808. White Blood Cell Function (Overview)

, differentiation, activation and apoptosis of the cells of the immune system. Some ILs, including IL2, also have antiviral and antitumoral functions. Interferons (-a, -b, -g) are involved in the regulation of immune responses and promote the activation and differentiation of the cells of the immune system. Interferons also possess antiviral and antitumoral properties. Tumor necrosis factor (TNF)-a and TNF-b have proinflammatory properties as well as antitumoral functions. Hematopoietic growth and survival (...) and severe immunopathologic conditions. Most parenchymal cells express IL-17 receptors; signaling through these receptors induces the target cells to produce proinflammatory factors, such as IL-6, IL-1, tumor necrosis (TNF), IL-8, and matrix metalloproteinases. [ ] Most cytotoxic T lymphocytes express CD8 and recognize endogenously derived antigens in the context of MHC class I molecules. They are critical in mediating allograft rejection, tumor surveillance, and destruction of intracellular pathogens

2014 eMedicine Pediatrics

809. Obesity (Follow-up)

are difficult to achieve and sustain in children and adolescents as well as adults, initiating counseling and therapy may be prudent with realistic goals that emphasize gradual reductions in body fat and BMI and maintenance of weight loss rather than a rapid return to ideal body weight. Reductions in body weight are accompanied by equivalent reductions in energy expenditure. Consequently, maintenance of a given weight in a patient with obesity necessitates a lower energy intake than maintenance (...) weight control. Exercise reduces weight accretion through increases in energy expenditure and has favorable effects on cardiovascular status, decreases body fat and total cholesterol levels, increases lean body mass and high-density lipoprotein (HDL) levels, and improves psychologic well-being. Controlled trials have demonstrated that lifestyle exercise programs, in association with dietary restrictions, provide long-term weight control in children and adolescents. The results from a systematic

2014 eMedicine Pediatrics

810. Disorders of the Breast (Follow-up)

. They are treated with complete surgical excision and can recur if not completely removed. Trauma Trauma to the breast, iatrogenic or blunt, may result in a palpable mass. The trauma causes fat necrosis, or breakdown of the adipose tissue. To complicate the diagnosis, women may or may not recall the inciting event. In addition, women may examine a traumatized breast and discover a mass that was present prior to the event. On physical examination, the mass is sometimes indistinguishable from a cancer. US (...) , mammography, and even magnetic resonance imaging (MRI) of the breast may be unable to discern the difference, leading to biopsies in concerning masses. Although pathognomonic for fat necrosis, key features—including peripheral calcifications, fibrotic scar, and echogenic internal bands—may also be consistent with breast cancer. [ ] Findings of lipid cysts or US evidence of fat necrosis may assist in the decision to monitor a palpable abnormality or perform a biopsy. [ ] Fibrocystic changes Fibrocystic

2014 eMedicine Pediatrics

811. Birth Trauma (Follow-up)

below): Abrasions Erythema petechia Ecchymosis Lacerations Subcutaneous fat necrosis Location of injury in soft tissue planes on the scalp and head. Skull injuries with a favorable long-term prognosis include the following: Caput succedaneum Cephalhematoma Linear fractures Facial injuries with a favorable long-term prognosis include the following: Subconjunctival hemorrhage Retinal hemorrhage Musculoskeletal injuries with a favorable long-term prognosis include the following: Clavicular fractures (...) sometimes may occur as scalpel cuts during cesarean delivery or during instrumental delivery (ie, vacuum, forceps). Infection remains a risk, but most of these lesions uneventfully heal. Management consists of careful cleaning, application of antibiotic ointment, and observation. Bring edges together using Steri-Strips. Lacerations occasionally require suturing. Subcutaneous fat necrosis Subcutaneous fat necrosis is not usually detected at birth. Irregular, hard, nonpitting, subcutaneous plaques

2014 eMedicine Pediatrics

812. Burns, Thermal (Follow-up)

go completely through the eschar. The subcutaneous fat will appear to bubble up into the escharotomy wound. Bleeding is minimal and is easily controlled by pressure. Upon completion of the escharotomy, a dressing with antibiotics is placed on the wound, and the extremity is elevated to help maintain homeostasis. If the chest is involved and the eschar compromises ventilatory motion, perform an escharotomy involving the anterior chest. Incisions are made along the costal margin, along the anterior (...) hypertonic fluid solutions is notably less, yet fluid requirements and percent weight gain have not been shown to be lower with hypertonic saline than with Ringer solution. The anticipated benefits of fewer escharotomies and limited ileus have not been uniformly encountered either. On the contrary, hypertonic saline resuscitation has been associated with an increased incidence of acute tubular necrosis and hyperchloremic metabolic acidosis, which can exacerbate the metabolic acidosis of hypovolemic shock

2014 eMedicine Pediatrics

813. Intraosseous Cannulation (Follow-up)

can also be limited by making only one attempt per tibia. Repeated attempts in the same bone allow fluid to flow through the previous holes produced in the bone. Extravasation of hypertonic or caustic medications, such as sodium bicarbonate, dopamine, or calcium chloride, can result in necrosis of the muscle. Infection and are relatively rare complications and occur most commonly if aseptic technique is not followed during insertion. Children with can develop this complication, as well. Cellulitis (...) at the insertion site has also been reported. Other possible complications include local hematoma, pain, fracture and growth plate injuries (with incorrect placement), and fat microemboli (not clinically significant) and compartment syndrome if extravasation is not recognized upon insertion. [ , ] With increased awareness of complications and improved training, complications may be less common than previously seen. [ ] Obtaining alternative IV access soon after the emergency and subsequent removal of the IO

2014 eMedicine Pediatrics

814. Birth Trauma (Treatment)

below): Abrasions Erythema petechia Ecchymosis Lacerations Subcutaneous fat necrosis Location of injury in soft tissue planes on the scalp and head. Skull injuries with a favorable long-term prognosis include the following: Caput succedaneum Cephalhematoma Linear fractures Facial injuries with a favorable long-term prognosis include the following: Subconjunctival hemorrhage Retinal hemorrhage Musculoskeletal injuries with a favorable long-term prognosis include the following: Clavicular fractures (...) sometimes may occur as scalpel cuts during cesarean delivery or during instrumental delivery (ie, vacuum, forceps). Infection remains a risk, but most of these lesions uneventfully heal. Management consists of careful cleaning, application of antibiotic ointment, and observation. Bring edges together using Steri-Strips. Lacerations occasionally require suturing. Subcutaneous fat necrosis Subcutaneous fat necrosis is not usually detected at birth. Irregular, hard, nonpitting, subcutaneous plaques

2014 eMedicine Pediatrics

815. Burns, Thermal (Treatment)

go completely through the eschar. The subcutaneous fat will appear to bubble up into the escharotomy wound. Bleeding is minimal and is easily controlled by pressure. Upon completion of the escharotomy, a dressing with antibiotics is placed on the wound, and the extremity is elevated to help maintain homeostasis. If the chest is involved and the eschar compromises ventilatory motion, perform an escharotomy involving the anterior chest. Incisions are made along the costal margin, along the anterior (...) hypertonic fluid solutions is notably less, yet fluid requirements and percent weight gain have not been shown to be lower with hypertonic saline than with Ringer solution. The anticipated benefits of fewer escharotomies and limited ileus have not been uniformly encountered either. On the contrary, hypertonic saline resuscitation has been associated with an increased incidence of acute tubular necrosis and hyperchloremic metabolic acidosis, which can exacerbate the metabolic acidosis of hypovolemic shock

2014 eMedicine Pediatrics

816. Weber-Christian Disease (Diagnosis)

: A, ×20; B, ×200.) Histopathologic features of subcutaneous fat necrosis of the newborn. (A) Scanning power shows a mostly lobular panniculitis (arrow indicates area enlarged in B). (B) Higher magnification demonstrated narrow needle-shaped clefts radially arranged and surrounded by histiocytes. (A and B, hematoxylin-eosin stain; original magnifications: A, X 20; B, X 200). Histopathologic features of lipoatrophy secondary to subcutaneous injections of corticosteroids. (A) Low-power view showed small (...) Updated: Aug 28, 2018 Author: Eyal Muscal, MD, MS; Chief Editor: Lawrence K Jung, MD Share Email Print Feedback Close Sections Sections Weber-Christian Disease Overview Background Panniculitis refers to a broad spectrum of diseases that involve inflammation of the subcutaneous fat layer of the skin. Weber-Christian disease is an eponym for a form of panniculitis, idiopathic nodular panniculitis, which is characterized by subcutaneous nodules, inflammatory cells in the fat lobules, and systemic

2014 eMedicine Pediatrics

817. Xenotransplantation (Diagnosis)

endothelial cells (pECs) and promote intravascular coagulation. After contact with human/primate blood, clots quickly develop in pECs. The increased clot formation may be immunologically mediated, or may be the result of specific hormone regulators. Lee et al. recently examined this question. [ ] Incubation of pECs with human tumor necrosis factor alpha (TNF-α) or interleukin-1α (IL-1α) caused an increase in porcine tissue factor (TF) activity and mRNA; however, those changes were not seen when (...) alginate macroencapsulation devices. [ ] Adult pig islet cells were encapsulated in microcapsules implanted in the kidney or in a subcutaneous macrodevice in streptozocin-treated cynomolgus monkeys; in the latter group, diabetes was controlled for 6 months without immune suppression. This remarkable advance could pave the way for a variety of future human trials. The regulation of T-regulatory cells Still another approach involves inducing host immune tolerance and tissue accommodation; if the host

2014 eMedicine Pediatrics

818. White Blood Cell Function (Diagnosis)

, differentiation, activation and apoptosis of the cells of the immune system. Some ILs, including IL2, also have antiviral and antitumoral functions. Interferons (-a, -b, -g) are involved in the regulation of immune responses and promote the activation and differentiation of the cells of the immune system. Interferons also possess antiviral and antitumoral properties. Tumor necrosis factor (TNF)-a and TNF-b have proinflammatory properties as well as antitumoral functions. Hematopoietic growth and survival (...) and severe immunopathologic conditions. Most parenchymal cells express IL-17 receptors; signaling through these receptors induces the target cells to produce proinflammatory factors, such as IL-6, IL-1, tumor necrosis (TNF), IL-8, and matrix metalloproteinases. [ ] Most cytotoxic T lymphocytes express CD8 and recognize endogenously derived antigens in the context of MHC class I molecules. They are critical in mediating allograft rejection, tumor surveillance, and destruction of intracellular pathogens

2014 eMedicine Pediatrics

819. Sickle Cell Anemia (Follow-up)

for the treatment of severe pain associated with a vasoocclusive crisis Use of analgesics and physical therapy for the treatment of avascular necrosis In July 2017, the US Food & Drug Administration (FDA) approved L-glutamine oral powder (Endari) for patients age 5 years and older to reduce severe complications of SCD. [ , ] L-glutamine increases the proportion of the reduced form of nicotinamide adenine dinucleotides in sickle cell erythrocytes; this probably reduces oxidative stress, which contributes (...) is an efficient iron chelator. It is administered as a prolonged infusion intravenously or subcutaneously for 5-7 days a week. Although effective, there are significant challenges associated with its use that can result in non-compliance. [ ] Deferiprone and deferasirox, oral iron chelators, are effective for iron overload treatment and have differences (eg, different pharmacokinetics and adverse effect profiles). Deferasirox has a capacity similar to deferoxamine in chelating iron, but it is administered

2014 eMedicine Pediatrics

820. Cellulitis (Diagnosis)

, the tissue is hemorrhagic and necrotic. Hematoxylin and eosin (H&E) stain, high power. This image shows deeper subcutaneous tissue involved in a case of cellulitis, with acute inflammatory cells and fat necrosis. Hematoxylin and eosin (H&E) stain, high power. This image shows cellulitis caused by herpes simplex virus, with the multinucleated organism in the center of the picture. of 14 Tables Table 1. Empiric Antibiotic Therapy for Cellulitis by Etiology and Anatomic Location Location Likely Organisms (...) E Herchline, MD; Chief Editor: Michael Stuart Bronze, MD Share Email Print Feedback Close Sections Sections Cellulitis Overview Practice Essentials The term cellulitis is commonly used to indicate a nonnecrotizing inflammation of the skin and subcutaneous tissues, usually from acute infection (see the image below). Cellulitis usually follows a breach in the skin, although a portal of entry may not be obvious; the breach may involve microscopic skin changes or invasive qualities of certain

2014 eMedicine Emergency Medicine

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