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effects of topical estrogen on cutaneous wound healing in healthy elderly men and women after receiving punch biopsies and related these effects to the inflammatory response and local elastase levels (a matrix metalloproteinase known to be upregulated in chronic wounds); it was found that compared to placebo treatment, estrogen treatment increased the extent of wound healing in both elderly males and females 13 These authors further determined that estrogen treatment was associated with a decrease in wound elastase levels secondary to reduced neutrophil numbers and decreased fibronectin degradation Similarly, an observational study showed that HRT recipients are approximately 30% to 40% less likely to develop a venous leg ulcer or a pressure ulcer than nonrecipients 32 In contrast, androgens appear to prolong inflammation and inhibit wound healing 14,33,34 Estrogen also promotes wound healing by increasing tissue expression of vascular endothelial growth factor (VEGF), an effect that is antagonized by androgens; therefore, estrogen can promote neovascularization that is necessary for wound healing while androgens inhibit it14 As estrogen has a direct stimulatory role on dermal fibroblasts, it also affects scarring Aged skin is associated with a reduced rate of cutaneous wound healing and improved quality of scarring, while young skin heals quickly but often with thick, visible scars Keloids and hypertrophic scars are generally conditions of youth, owing to an increase in TGF- production by dermal fibroblasts, while scarless wound healing is a characteristic of fetal skin that, like aged skin, has lower levels of TGF- 35 As estrogen is known to increase TGF- , and is therefore profibrotic, antiestrogens such as tamoxifen have been shown to decrease TGF- levels,36,37 and are antifibrotic Therefore, tamoxifen or other estrogen receptor modulators may be useful in improving scar cosmesis

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Resource: 5 TLT 10 days : VA Time: 1 hr AIP: 200 Rework: 5%

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In addition to simply retrieving data, we often want to perform some computation or summarization As we noted earlier in this chapter, SQL allows the use of arithmetic expressions We now consider a powerful class of constructs for computing aggregate values such as MIN and SUM These features represent a signi cant extension of relational algebra SQL supports ve aggregate operations, which can be applied on any column, say A, of a relation: 1 COUNT ([DISTINCT] A): The number of (unique) values in the A column 2 SUM ([DISTINCT] A): The sum of all (unique) values in the A column 3 AVG ([DISTINCT] A): The average of all (unique) values in the A column 4 MAX (A): The maximum value in the A column 5 MIN (A): The minimum value in the A column Note that it does not make sense to specify DISTINCT in conjunction with MIN or MAX (although SQL-92 does not preclude this) (Q25) Find the average age of all sailors SELECT AVG (Sage) FROM Sailors S On instance S3, the average age is 374 Of course, the WHERE clause can be used to restrict the sailors who are considered in computing the average age: (Q26) Find the average age of sailors with a rating of 10 SELECT AVG (Sage) FROM Sailors S WHERE Srating = 10 There are two such sailors, and their average age is 255 MIN (or MAX) can be used instead of AVG in the above queries to nd the age of the youngest (oldest) sailor

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benefits from estrogen therapy, as estrogens are known to affect several organ systems, this subject is best addressed on a case-by-case basis and as part of a team approach with other physicians so that all risks and benefits are weighed The primary risks associated with HRT are related to breast cancer and cardiovascular health; the primary benefits include relief of menopausal symptoms (such as vasomotor instability, sexual dysfunction, mood fluctuation, and skin atrophy) and a decrease in fracture risk Current recommendations specify that HRT should only be used short term, for moderate to severe vasomotor symptoms, and primarily in younger women who are close to menopause (early menopause or first 5 years after menopause) It is important to note that estrogen-containing creams are contraindicated for women who have been diagnosed with estrogen-responsive cancers Regarding the use of topical versus oral estrogens, topical estrogens are easily absorbed (hence the popularity of estrogen replacement in patch or gel form), but the cutaneous route avoids hepatic first-pass metabolism and high plasma levels of estrogen metabolites are associated with oral administration

Resource: 35 TLT: 8 days VA Time: 2 hr AIP: 560 Rework: 1%

among patients with acne vulgaris J Am Acad Dermatol 2007;57:222 79 Elias PM Stratum corneum defensive functions: an integrated view J Invest Dermatol 2005;125:183 80 Kao JS, Fluhr JW, Man MQ, et al Short-term glucocorticoid treatment compromises both permeability barrier homeostasis and stratum corneum integrity: inhibition of epidermal lipid synthesis accounts for functional abnormalities J Invest Dermatol 2003;120:456 81 Choi EH, Brown BE, Crumrine D, et al Mechanisms by which psychologic stress alters cutaneous permeability

Resource: 2 TLT: 3 days VA Time: 1 hr AIP: 210 Rework: 12%

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