Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review

BACKGROUND

Prophylactic antibiotic therapy is widely used in dermatologic surgery to prevent surgical site infections and bacteremia, which can lead to prosthetic joint infections (PJI) and infective endocarditis (IE) in high-risk populations.

OBJECTIVE

To evaluate the incidence of bacteremia, PJI, and IE after dermatologic surgery and assess the current evidence for antibiotic prophylaxis.

MATERIALS AND METHODS

A search of the computerized bibliographic databases was performed using key terms from the date of inception to March 21, 2021. Data extraction was performed independently by 2 data extractors.

RESULTS

The review resulted in 9 publications that met inclusion criteria, including 5 prospective cohort studies and 4 case reports or case series. The prospective studies reported a wide range of bacteremia incidence (0%-7%) after dermatologic surgery. No cases of PJI resulting directly from cutaneous surgery were identified, and only 1 case series reported IE after various skin procedures.

CONCLUSION

These findings suggest a low rate of bacteremia and a lack of direct evidence linking dermatologic surgery to PJI or IE. The scarcity of published data on this topic is a limitation, highlighting the need for further research, particularly randomized controlled trials, to guide antibiotic prophylaxis recommendations.

A Systematic Review of the Epidemiology, Clinical Characteristics, Treatment, and Outcomes for Desmoplastic Trichoepithelioma: Underscoring Mohs Micrographic Surgery in Management

BACKGROUND

Desmoplastic trichoepithelioma (DTE) is an uncommon benign adnexal tumor that histologically may mimic malignant tumors including basal cell carcinoma and microcystic adnexal carcinoma.

OBJECTIVE

To present a systematic review of the epidemiology, clinical characteristics, treatment, and outcome data on DTEs, with emphasis on comparing Mohs micrographic surgery (MMS) with other treatments.

METHODS

Using the OVID platform, MEDLINE and Embase were searched from inception for studies providing original data on DTEs.

RESULTS

A total of 338 cases of DTE from 61 articles were included. No recurrence/persistence (0%) was reported following MMS (n = 24, mean follow-up of 41.9 months), 13.1% with standard excision (n = 38, mean follow-up 16.9 months), and 2.1% for electrosurgery/cautery (n = 49, follow-up 3-72 months). 100% recurrence/persistence for imiquimod (n = 2) and liquid nitrogen (n = 4) were identified. In patients who underwent biopsy only, there was a 12.5% recurrence/persistence (n = 32, mean follow-up 16.5 months). Overall, duration of follow-up varied from 2 months to 6 years for the various management strategies.

CONCLUSION

Data are limited regarding DTE outcomes. In this review, surgical modalities, specifically MMS, had the lowest rates of recurrence/persistence compared with other options. Given that most lesions are found on cosmetically sensitive locations, MMS seems to be the optimal management strategy for actively managing DTEs.

Visualizing Noncovalent Interactions and Property Prediction of Submicron-Sized Charge-Transfer Crystals from ab-initio Determined Structures

The charge-transfer (CT) interactions between organic compounds are reflected in the (opto)electronic properties. Determining and visualizing crystal structures of CT complexes are essential for the design of functional materials with desirable properties. Complexes of pyranine (PYR), methyl viologen (MV), and their derivatives are the most studied water-based CT complexes. Nevertheless, very few crystal structures of CT complexes have been reported so far. In this study, the structures of two PYRs-MVs CT crystals and a map of the noncovalent interactions using 3D electron diffraction (3DED) are reported. Physical properties, e.g., band structure, conductivity, and electronic spectra of the CT complexes and their crystals are investigated and compared with a range of methods, including solid and liquid state spectroscopies and highly accurate quantum chemical calculations based on density functional theory (DFT). The combination of 3DED, spectroscopy, and DFT calculation can provide important insight into the structure-property relationship of crystalline CT materials, especially for submicrometer-sized crystals.

Nasal Lining Repair: A Comprehensive Literature Review

BACKGROUND

Currently, there are limited reviews in the dermatology literature on how to approach reconstruction of nasal lining in full-thickness nasal defects resulting from Mohs micrographic surgery. Given variable training and experience, dermatologic surgeons may seek additional references to help reconstruct certain advanced defects. We sought to synthesize literature from dermatologic surgery, plastic surgery, and otolaryngology to review repair options and considerations for repair of nasal lining defects.

OBJECTIVE

To present a comprehensive literature review of repair options for nasal lining reconstruction and discuss advantages, disadvantages, specific anatomic considerations, and techniques to execute such options.

MATERIALS AND METHODS

Articles from several different reconstructive specialties including dermatologic/Mohs surgery, otolaryngology, and plastic and reconstructive surgery were reviewed. Instructive images were compiled to illustrate several techniques, with additional medical illustration recreations included to help showcase important reconstructive approaches.

RESULTS

A comprehensive descriptive review of nasal lining repair options for the reconstructive surgeon.

CONCLUSION

Advanced tumors can result in full-thickness nasal defects, and this review describes various reconstructive options for reconstruction based on the extent of the defect.

Aerosol source apportionment uncertainty linked to the choice of input chemical components

For a Positive Matrix Factorization (PMF) aerosol source apportionment (SA) studies there is no standard procedure to select the most appropriate chemical components to be included in the input dataset for a given site typology, nor specific recommendations in this direction. However, these choices are crucial for the final SA outputs not only in terms of number of sources identified but also, and consequently, in the source contributions estimates. In fact, PMF tends to reproduce most of PM mass measured independently and introduced as a total variable in the input data, regardless of the percentage of PM mass which has been chemically characterized, so that the lack of some specific source tracers (e.g. levoglucosan) can potentially affect the results of the whole source apportionment study. The present study elaborates further on the same concept, evaluating quantitatively the impact of lacking specific sources' tracers on the whole source apportionment, both in terms of identified sources and source contributions. This work aims to provide first recommendations on the most suitable and critical components to be included in PMF analyses in order to reduce PMF output uncertainty as much as possible, and better represent the most commons PM sources observed in many sites in Western countries. To this aim, we performed three sensitivity analyses on three different datasets across EU, including extended sets of organic tracers, in order to cover different types of urban conditions (Mediterranean, Continental, and Alpine), source types, and PM fractions. Our findings reveal that the vehicle exhaust source resulted to be less sensitive to the choice of analytes, although source contributions estimates can deviate significantly up to 44 %. On the other hand, for the detection of the non-exhaust one is clearly necessary to analyze specific inorganic elements. The choice of not analysing non-polar organics likely causes the loss of separation of exhaust and non-exhaust factors, thus obtaining a unique road traffic source, which provokes a significant bias of total contribution. Levoglucosan was, in most cases, crucial to identify biomass burning contributions in Milan and in Barcelona, in spite of the presence of PAHs in Barcelona, while for the case of Grenoble, even discarding levoglucosan, the presence of PAHs allowed identifying the BB factor. Modifying the rest of analytes provoke a systematic underestimation of biomass burning source contributions. SIA factors resulted to be generally overestimated with respect to the base case analysis, also in the case that ions were not included in the PMF analysis. Trace elements were crucial to identify shipping emissions (V and Ni) and industrial sources (Pb, Ni, Br, Zn, Mn, Cd and As). When changing the rest of input variables, the uncertainty was narrow for shipping but large for industrial processes. Major and trace elements were also crucial to identify the mineral/soil factor at all cities. Biogenic SOA and Anthropogenic SOA factors were sensitive to the presence of their molecular tracers, since the availability of OC alone is unable to separate a SOA factor. Arabitol and sorbitol were crucial to detecting fungal spores while odd number of higher alkanes (C27 to C31) for plant debris.

Excision margins for melanoma in situ on the head and neck-A single-center 10-year retrospective review of treatment with Mohs micrographic surgery

BACKGROUND

Although current guidelines recommend a 5 mm surgical margin for the excision of melanoma in situ (MIS), increasing evidence has shown this may be suboptimal to achieve tumor clearance.

OBJECTIVE

To evaluate margins required for optimal cure rates with excision of MIS on the head and neck and investigate tumor and/or patient factors in those requiring >5 mm margins to achieve tumor clearance.

METHODS

A retrospective chart review was performed on 846 (807 primary and 39 recurrent) MIS cases on the head and neck treated in the authors' dermatologic surgery department over a 126-month (10.5 year) period.

RESULTS

Sixty-two percent were cleared with 5 mm margins. A total of 15 mm margins were required to achieve a 97% clearance rate. Difference in clearance rate between margin thresholds was significant (P < .001). Tumor location on the cheek and larger preoperative size correlated with requiring >5 mm margins to achieve tumor clearance (P = .006 and P = .001, respectively).

LIMITATIONS

This is a single-center retrospective study which relies on accurate documentation of clinical data.

CONCLUSION

This study demonstrates that MIS on the head and neck often requires margins >5 mm margins to achieve tumor clearance. When Mohs micrographic surgery is not possible, excision margins of ≥10 mm are likely necessary for head and neck tumors.

Comparison of palonosetron and ondansetron in preventing postoperative nausea and vomiting in renal transplantation recipients: a randomized clinical trial

BACKGROUND

End-stage renal diseases patients have a high risk of postoperative nausea and vomiting (PONV), which is multifactorial and need acute attention after renal transplantation for a successful outcome in term of an uneventful postoperative period. The study was done to compare the efficacy of palonosetron and ondansetron in preventing early and late-onset PONV in live donor renal transplantation recipients (LDRT).

METHODS

The prospective randomized double-blinded study was done on 112 consecutive patients planned for live donor renal transplantation. Patients of both sexes in the age group of 18...60 years were randomly divided into two groups: Group O (Ondansetron) and Group P (Palonosetron) with 56 patients in each group by computer-generated randomization. The study drug was administered intravenously (IV) slowly over 30.ßseconds, one hour before extubation. Postoperatively, the patients were accessed for PONV at 6, 24, and 72.ßhours using the Visual Analogue Scale (VAS) nausea score and PONV intensity scale.

RESULTS

The incidence of PONV in the study was found to be 30.35%. There was significant difference in incidence of PONV between Group P and Group O at 6.ßhours (12.5% vs. 32.1%, p.ß=.ß0.013) and 72.ßhours (1.8% vs. 33.9%, p.ß<.ß0.001), but insignificant difference at 24.ßhours (1.8% vs. 10.7%, p.ß=.ß0.113). VAS-nausea score was significantly lower in Group P as compared to Group O at a time point of 24.ßhours (45.54.ß...ß12.64 vs. 51.96.ß...ß14.70, p.ß=.ß0.015) and 72.ßhours (39.11.ß...ß10.32 vs. 45.7.ß...ß15.12, p.ß=.ß0.015).

CONCLUSION

Palonosetron is clinically superior to ondansetron in preventing early and delayed onset postoperative nausea and vomiting in live-related renal transplant recipients.

NCCN Guidelines® Insights: Merkel Cell Carcinoma, Version 1.2024

The NCCN Guidelines for Merkel Cell Carcinoma (MCC) provide recommendations for diagnostic workup, clinical stage, and treatment options for patients. The panel meets annually to discuss updates to the guidelines based on comments from expert review from panel members, institutional review, as well as submissions from within NCCN and external organizations. These NCCN Guidelines Insights focus on the introduction of a new page for locally advanced disease in the setting of clinical node negative status, entitled "Clinical N0 Disease, Locally Advanced MCC." This new algorithm page addresses locally advanced disease, and the panel clarifies the meaning behind the term "nonsurgical" by further defining locally advanced disease. In addition, the guideline includes the management of in-transit disease and updates to the systemic therapy options.

Clinical Outcomes in Sebaceous Carcinoma: A Retrospective Two-Center Cohort Study

BACKGROUND

Sebaceous carcinoma (SC) is a rare, potentially recurrent, and life-threatening cutaneous malignancy that can be associated with Muir-Torre syndrome (MTS), a DNA mismatch repair-driven genodermatosis. Earlier studies examining factors associated with recurrence have focused on periocular tumors only.

OBJECTIVE

Examine outcomes of SC and identify factors associated with recurrence.

MATERIALS AND METHODS

Retrospective study from 2 tertiary care centers.

RESULTS

Sixty-seven cases from 63 patients were identified, including 7 cases of MTS and 13 arising in the context of immunosuppression. Fifty-five cases (82.1%) were treated with complete circumferential peripheral and deep margin assessment (CCPDMA) methods. Five recurrences developed during the postoperative period. On univariate analysis, periocular location (odds ratio [OR] 7.6, p = .0410), and lesion size ≥2 cm (OR 9.6, p = .005) were associated with recurrence, whereas CCPDMA (OR 0.052, p = .0006) was inversely associated with recurrence. On multivariate analysis, only lesion size ≥2 cm (OR 9.6, p = .0233) and CCPDMA approaches (OR 0.052, p = .007) were significant.

CONCLUSION

Non-complete circumferential peripheral and deep margin assessment methods and large lesion size were independent risk factors predicting recurrence, whereas anatomic subtype and MTS status were not. These findings can assist in identifying SC cases that may benefit from more aggressive treatment and closer surveillance.

Outcomes of Squamous Cell Carcinoma of the Lip Treated With Mohs Micrographic Surgery: A Retrospective Cohort Study

BACKGROUND

Cutaneous squamous cell carcinomas (cSCCs) of the lip have been reported to be at higher risk for poorer post-treatment outcomes.

OBJECTIVE

To examine outcomes of patients with SCC of the lip treated with Mohs micrographic surgery (MMS) and identify factors for recurrence.

MATERIALS AND METHODS

This retrospective review of a single tertiary referral center's Mohs case logs from 2010 to 2019 identified cases of lip SCC. Clinicopathologic characteristics and outcomes (local recurrence [LR], metastasis, and disease-specific death) were reviewed.

RESULTS

One hundred ninety cases of SCC of the lip were identified and demonstrated that MMS offered a disease-free survival of 96.8% over an average follow-up period of 42 months. Younger age (61 vs 74 years p = .006), increased MMS stages ( p = .009), and higher American Joint Committee on Cancer and Brigham and Women's Hospital T stages were risk factors for LR. Immunosuppression, large tumor size, mucosal lip involvement, aggressive histology, and perineural invasion were not associated with LR.

CONCLUSION

The results of this study show that SCC of the lip behaved similarly to cSCC outside the lip area, and that both primary and recurrent lesions can be treated effectively with MMS.

Basal Cell Skin Cancer, Version 2.2024, NCCN Clinical Practice Guidelines in Oncology

Basal cell carcinoma (BCC) is the most common form of skin cancer in the United States. Due to the high frequency, BCC occurrences are not typically recorded, and annual rates of incidence can only be estimated. Current estimated rates are 2 million Americans affected annually, and this continues to rise. Exposure to radiation, from either sunlight or previous medical therapy, is a key player in BCC development. BCC is not as aggressive as other skin cancers because it is less likely to metastasize. However, surgery and radiation are prevalent treatment options, therefore disfigurement and limitation of function are significant considerations. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) outline an updated risk stratification and treatment options available for BCC.

A Framework for Digital Health Policy: Insights from Virtual Primary Care Systems Across Five Nations

Digital health technologies used in primary care, referred to as, virtual primary care, allow patients to interact with primary healthcare professionals remotely though the current iteration of virtual primary care may also come with several unintended consequences, such as accessibility barriers and cream skimming. The World Health Organization (WHO) has a well-established framework to understand the functional components of health systems. However, the existing building blocks framework does not sufficiently account for the disruptive and multi-modal impact of digital transformations. In this review, we aimed to develop the first iteration of this updated framework by reviewing the deployment of virtual primary care systems in five leading countries: Canada, Finland, Germany and Sweden and the United Kingdom (England). We found that all five countries have taken different approaches with the deployment of virtual primary care, yet seven common themes were highlighted across countries: (1) stated policy objectives, (2) regulation and governance, (3) financing and reimbursement, (4) delivery and integration, (5) workforce training and support, (6) IT systems and data sharing, and (7) the extent of patient involvement in the virtual primary care system. The conceptual framework that was derived from these findings offers a set of guiding principles that can facilitate the assessment of virtual primary care in health system settings.

Promoting the systematic use of real-world data and real-world evidence for digital health technologies across Europe: a consensus framework

Despite the acceleration in the use of digital health technologies across different aspects of the healthcare system, the full potential of real-world data (RWD) and real-world evidence (RWE) arising from the technologies is not being utilised in decision-making. We examine current national efforts and future opportunities to systematically use RWD and RWE in decision-making in five countries (Estonia, Finland, Germany, Italy and the United Kingdom), and then develop a framework for promotion of the systematic use of RWD and RWE. A review assesses current national efforts, complemented with a three-round consensus-building exercise among an international group of experts (n1 = 44, n2 = 24, n3 = 24) to derive key principles. We find that Estonia and Finland have invested and developed digital health-related policies for several years; Germany and Italy are the more recent arrivals, while the United Kingdom falls somewhere in the middle. Opportunities to promote the systematic use of RWD and RWE were identified for each country. Eight building blocks principles were agreed through consensus, relating to policy scope, institutional role and data collection. Promoting post-market surveillance and digital health technology vigilance ought to rely on clarity in scope and data collection with consensus reached on eight principles to leverage RWD and RWE.

Digital Health Reimbursement Strategies of 8 European Countries and Israel: Scoping Review and Policy Mapping

BACKGROUND

The adoption of digital health care within health systems is determined by various factors, including pricing and reimbursement. The reimbursement landscape for digital health in Europe remains underresearched. Although various emergency reimbursement decisions were made during the COVID-19 pandemic to enable health care delivery through videoconferencing and asynchronous care (eg, digital apps), research so far has primarily focused on the policy innovations that facilitated this outside of Europe.

OBJECTIVE

This study examines the digital health reimbursement strategies in 8 European countries (Belgium, France, Germany, Italy, the Netherlands, Poland, Sweden, and the United Kingdom) and Israel.

METHODS

We mapped available digital health reimbursement strategies using a scoping review and policy mapping framework. We reviewed the literature on the MEDLINE, Embase, Global Health, and Web of Science databases. Supplementary records were identified through Google Scholar and country experts.

RESULTS

Our search strategy yielded a total of 1559 records, of which 40 (2.57%) were ultimately included in this study. As of August 2023, digital health solutions are reimbursable to some extent in all studied countries except Poland, although the mechanism of reimbursement differs significantly across countries. At the time of writing, the pricing of digital health solutions was mostly determined through discussions between national or regional committees and the manufacturers of digital health solutions in the absence of value-based assessment mechanisms. Financing digital health solutions outside traditional reimbursement schemes was possible in all studied countries except Poland and typically occurs via health innovation or digital health-specific funding schemes. European countries have value-based pricing frameworks that range from nonexistent to embryonic.

CONCLUSIONS

Studied countries show divergent approaches to the reimbursement of digital health solutions. These differences may complicate the ability of patients to seek cross-country health care in another country, even if a digital health app is available in both countries. Furthermore, the fragmented environment will present challenges for developers of such solutions, as they look to expand their impact across countries and health systems. An increased emphasis on developing a clear conceptualization of digital health, as well as value-based pricing and reimbursement mechanisms, is needed for the sustainable integration of digital health. This study can therein serve as a basis for further, more detailed research as the field of digital health reimbursement evolves.

The inclusion of diagnostics in national health insurance schemes in Cambodia, India, Indonesia, Nepal, Pakistan, Philippines and Viet Nam

The Lancet Commission on Diagnostics highlighted a huge gap in access to diagnostic testing even for basic tests, particularly at the primary care level, and emphasised the need for countries to include diagnostics as part of their universal health coverage benefits packages. Despite the poor state of diagnostic-related services in low-income and middle-income countries (LMICs), little is known about the extent to which diagnostics are included in the health benefit packages. We conducted an analysis of seven Asian LMICs-Cambodia, India, Indonesia, Nepal, Pakistan, Philippines, Viet Nam-to understand this issue. We conducted a targeted review of relevant literature and applied a health financing framework to analyse the benefit packages available in each government-sponsored scheme. We found considerable heterogeneity in country approaches to diagnostics. Of the seven countries, only India has developed a national essential diagnostics list. No country presented a clear policy rationale on the inclusion of diagnostics in their scheme and the level of detail on the specific diagnostics which are covered under the schemes was also generally lacking. Government-sponsored insurance expansion in the eligible populations has reduced the out-of-pocket health payment burden in many of the countries but overall, there is a lack of access, availability and affordability for diagnostic-related services.

Cost effectiveness of melanoma in situ resection and repair by dermatology compared to non-dermatology specialties at a single institution

Melanoma-in-situ (MIS) is treated with surgical resection by many specialties. Dermatologists perform these procedures in outpatient settings while others often employ operating rooms and general anesthesia. We hypothesized that MIS managed by dermatology was less costly than that managed by other specialties. All cases of MIS treated at our institution over a 3-year period were evaluated retrospectively for demographic and clinical characteristics and categorized by treating specialty. Estimated cost information was determined using records of charges billed. The mean total cost for MIS treated with wide local excision (WLE) by dermatologists was $1089 (CI = $941-1237) versus all other specialties at $5172 (CI = $2419-7925) (p < 0.001). MIS treated with Mohs micrographic surgery and repaired by dermatology (mean = $2325, CI = $2241-2409) was also less expensive than MIS treated by other specialties with WLE (p < 0.001). The results suggest MIS is significantly less costly to patients and the health care system when treatment is performed by dermatologists compared to other surgical specialties. This is likely due to dermatologists performing the procedures in less expensive outpatient settings.

Newer frontiers in onco-anaesthesia and palliative medicine

Despite an increase in knowledge on the biology of cancer and newer therapeutic modalities, the incidence and mortality of cancer continue to rise. Interventions to enhance perioperative outcomes in cancer is a growing research area that targets early recovery and initiation of cancer-specific treatment. Increasing mortality in non-communicable diseases such as cancer mandates an integrated palliative care for these patients to achieve the best possible quality of life. The aim of this review is to discuss in brief the advancements in onco-anaesthesia and palliative medicine that have helped improve oncological outcomes and the quality of life of patients.

Difference in Antihypertensive Medication Pattern in the First Year Compared to More than a Year of Maintenance Hemodialysis: A Northern India Tertiary Care Experience

Introduction There is a high prevalence of hypertension in maintenance hemodialysis patients. Information regarding prevalent pattern of antihypertensive medications will help modify it to prevent future cardiovascular morbidity and mortality.

Materials and Methods In this cross-sectional study, patients on maintenance hemodialysis, aged ≥18 years visiting Nephrology outpatient department (OPD) from April 2019 to May 2020 were included. The patients were divided into two groups based on their dialysis vintage, ≤12 months and >12 months. Their antihypertensive medication patterns and two-dimensional (2D) echocardiography (ECHO) findings were compared. Independent t-test was used to compare continuous variables. One-way analysis of variance was used to study the antihypertensive drug-dosing pattern in both the groups.

Results Out of 250 patients, 131 had a dialysis vintage of ≤12 months, whereas 119 had a vintage of >12 months. There was no significant difference in the number of antihypertensive agents used in either of the vintage groups. Calcium channel blockers (87.02 and 89.07%, respectively, in ≤12 and >12 months' vintage groups) and β blockers (64.12 and 65.54%, respectively, in ≤12 and >12 months' vintage groups) were the commonly used antihypertensive agents. Metoprolol use was higher in ≤12 months' group, whereas carvedilol usage was higher in >12 months' group (p = 0.028). Mean pill burden was more than five in both the groups. Concentric left ventricular hypertrophy was significantly more common in >12 months' group. Renin–angiotensin system (RAS) blocking agent use was limited to 3% of patients.

Conclusion This study shows a high antihypertensive pill burden in dialysis patients likely due to underlying chronic volume overload in addition to the perceived efficacy of certain class of drug in a frequent dosing pattern. Low use of RAS blocking agent was also underlined. This study highlights the need to bring about changes in the antihypertensive prescription pattern in line with the existing evidence.

Inferiorly Based Rotation Flaps for Infraorbital Cheek Defects

BACKGROUND

The infraorbital cheek is a common location for cutaneous malignancy and thus surgical defects. Reconstruction in this region must maintain nearby free margins to ensure optimal cosmetic and functional outcomes. Large defects may require a flap using lateral or inferior tissue reservoirs.

OBJECTIVE

To examine outcomes of inferiorly based rotation flaps in the repair of infraorbital cheek defects and highlight pearls for optimal long-term results.

METHODS

Chart review of patients with a defect of the infraorbital cheek repaired with an inferiorly based rotation flap between February 2010 and December 2018 at a single academic institution. The Visual Analog Scale (VAS) was used for scar assessment.

RESULTS

Sixty-five patients underwent extirpation of a cutaneous malignancy resulting in defects ranging from 1.0 × 1.0 to 4.5 × 5.5 cm (mean area = 4.8 cm2). Most of the patients did not experience complications. Ectropion occurred in 7 patients. The mean VAS score was 11.6.

CONCLUSION

An inferiorly based rotation flap yields acceptable outcomes for infraorbital cheek defects and can be considered for defects as large as 5.5 cm. Using pearls for surgical execution presented in this article may allow reconstructive surgeons to include this flap in their repertoire.

NCCN Guidelines® Insights: Squamous Cell Skin Cancer, Version 1.2022

The NCCN Guidelines for Squamous Cell Skin Cancer provide recommendations for diagnostic workup, clinical stage, and treatment options for patients with cutaneous squamous cell carcinoma. The NCCN panel meets annually to discuss updates to the guidelines based on comments from panel members and the Institutional Review, as well as submissions from within NCCN and external organizations. These NCCN Guidelines Insights focus on the introduction of a new surgical recommendation terminology (peripheral and deep en face margin assessment), as well as recent updates on topical prophylaxis, immunotherapy for regional and metastatic disease, and radiation therapy.

Systematic Review of Technical Variations for Mohs Micrographic Surgery for Melanoma

BACKGROUND

Mohs micrographic surgery (MMS) for cutaneous melanoma is becoming more prevalent, but surgical technique varies.

OBJECTIVE

To define variations in published techniques for MMS for melanoma.

METHODS AND MATERIALS

A systematic review was performed of PubMed, EMBASE, and Scopus databases to identify all articles describing surgical techniques for MMS for melanoma. Technical details were recorded for the preoperative, intraoperative, and postoperative phases of MMS.

RESULTS

Twenty-four articles were included. Mohs surgeons vary in how they assess clinical margins, how wide a margin they excise on the first MMS layer, and how they process tissue to determine tumor stage and margin clearance during MMS for melanoma.

CONCLUSION

Mohs micrographic surgery for melanoma is performed with varied surgical techniques. To establish best practices, additional research is necessary to determine how different techniques affect outcomes.

A Simple Modification of Sphenopalatine Ganglion Block for Treatment of Postdural Puncture Headache: A Case Series

To evaluate the efficacy of modified sphenopalatine ganglion block (MSPGB) to reduce the severity of post-dural puncture headache (PDPH). Five adult patients of both genders with age >18 years having PDPH intractable to conservative management were given modified sphenopalatine block in the postoperative period, and numeric rating scale (NRS) was recorded at regular intervals till the hospital discharge. MSPGB is a simple, noninvasive technique that provides instantaneous symptomatic relief in PDPH.

Important innate differences in determining symbiotic responsiveness in host and non-hosts of arbuscular mycorrhiza

Genetic components that regulate arbuscular mycorrhizal (AM) interactions in hosts and non-hosts are not completely known. Comparative transcriptomic analysis was combined with phylogenetic studies to identify the factors that distinguish AM host from non-host. Mycorrhized host, non-mycorrhized host and non-host cultivars of tomato (Solanum lycopersicum) were subjected to RNA seq analysis. The top 10 differentially expressed genes were subjected to extensive in silico phylogenetic analysis along with 10 more candidate genes that have been previously reported for AM-plant interactions. Seven distantly related hosts and four non-hosts were selected to identify structural differences in selected gene/protein candidates. The screened genes/proteins were subjected to MEME, CODEML and DIVERGE analysis to identify evolutionary patterns that differentiate hosts from non-hosts. Based on the results, candidate genes were categorized as highly influenced (SYMRK and CCaMK), moderately influenced and minimally influenced by evolutionary constraints. We propose that the amino acid and nucleotide changes specific to non-hosts are likely to correspond to aberrations in functionality towards AM symbiosis. This study paves way for future research aimed at understanding innate differences in genetic make-up of AM hosts and non-hosts, in addition to the theory of gene losses from the "AM-symbiotic toolkit".

High-Risk Cutaneous Squamous Cell Carcinoma of the Head and Neck: A Clinical Review

BACKGROUND

Given the rapidly evolving nature of the field, the current state of "high-risk" head and neck cutaneous squamous cell carcinoma (HNcSCC) is poorly characterized.

METHODS

Narrative review of the epidemiology, diagnosis, workup, risk stratification, staging and treatment of high-risk HNcSCC.

RESULTS

Clinical and pathologic risk factors for adverse HNcSCC outcomes are nuanced (e.g., immunosuppression and perineural invasion). Frequent changes in adverse prognosticators have outpaced population-based registries and the variables they track, restricting our understanding of the epidemiology of HNcSCC and inhibiting control of the disease. Current heterogeneous staging and risk stratification systems are largely derived from institutional data, compromising their external validity. In the absence of staging system consensus, tumor designations such as "high risk" and "advanced" are variably used and insufficiently precise to guide management. Evidence guiding treatment of high-risk HNcSCC with curative intent is also suboptimal. For patients with incurable disease, an array of trials are evaluating the impact of immunotherapy, targeted biologic therapy, and other novel agents.

CONCLUSION

Population-based registries that broadly track updated, nuanced, adverse clinicopathologic risk factors, and outcomes are needed to guide development of improved staging systems. Design and development of randomized controlled trials (RCTs) in advanced-stage HNcSCC populations are needed to evaluate (1) observation, sentinel lymph node biopsy, or elective neck dissection for management of the cN0 neck, (2) indications for surgery plus adjuvant radiation versus adjuvant chemoradiation, and (3) the role of immunotherapy in treatment with curative intent. Considering these knowledge gaps, the authors explore a potential high-risk HNcSCC treatment framework.

Wound care quality of life in aging patients undergoing electrodessication and curettage on the back

Patient satisfaction is an important consideration when determining the optimal treatment for non-melanoma skin cancer (NMSC). One critical aspect of patient satisfaction is post-procedural wound care quality of life (QOL), especially as the elderly population grows. This study aimed to evaluate post-procedural wound care QOL in elderly patients undergoing electrodessication and curettage (ED&C) for NMSC in difficult-to-reach areas, namely the posterior shoulder and back. To do so, patient demographics, functionality, co-morbidities, and post-procedural wound care QOL were assessed in twenty elderly patients (age > 65) who underwent ED&C for NMSC at a single academic dermatologic surgery clinic. Independent t-tests were used to evaluate how QOL related to patient age, gender, living situation, relationship status, co-morbidities, and functionality. Patients who lived alone had better-wound care QOL compared to patients who did not live alone (p = 0.04). Patients reported concerns about knocking the wound and did not feel they could care for the wound independently. Patients who were married, female, or had a lower comorbidity score reported poorer QOL, although this finding was not statistically significant. This study indicates that patients' QOL can be negatively affected by post-procedural wounds located in difficult-to-reach areas. As dermatologists strive to improve patient satisfaction, wound care quality of life should be considered when choosing treatment for NMSC.

Basal cell carcinoma histopathologic upgrading and Mohs micrographic surgery: a single institution, retrospective review

Basal cell carcinoma (BCC) histopathology can differ between original biopsy and wide local excision or Mohs micrographic surgery (MMS). We aimed to analyze the rate of difference in BCC subtypes between the original biopsy and MMS frozen section to determine the rate of histopathological upgrading and also to identify risk factors for upgrading. A single institution, retrospective cohort study of patients with BCC treated with MMS was performed at the University of Texas Southwestern. Screening criteria identified 3235 BCCs. Of these, 1289 tumors were identified as having lower-grade pathology on initial biopsy. 291 (22.6%) of the lower-grade pathology tumors were upgraded to a higher-grade pathology. Tumors with an upgraded pathology had significantly greater number of stages performed [mean of 2.5 vs 2.3, p < 0.001], pre-operative size [median of 1.0 cm vs 0.8 cm, p < 0.001], and post-operative size [median of 2.0 cm vs 1.7 cm, p < 0.001]. These tumors were significantly more likely to require more advanced repairs [36.8% (107/291) vs 29.8% (297/998), p = 0.03] and be referred for post-operative radiation [1.7% (5/291) vs 0.0% (0/998), p < 0.001]. In addition, there were a significantly greater number of tumors considered recurrent (received prior surgical or non-surgical treatment) in the upgraded pathology group [8.6% (25/291) vs 3.9% (39/998), p < 0.01]. Our study highlights that a significant proportion of these patients are under-graded on initial biopsy and would benefit from more definitive intervention, such as MMS.

One-year measurements of secondary organic aerosol (SOA) markers in the Paris region (France): Concentrations, gas/particle partitioning and SOA source apportionment

Twenty-five biogenic and anthropogenic secondary organic aerosol (SOA) markers have been measured over a one-year period in both gaseous and PM₁₀ phases in the Paris region (France). Seasonal and chemical patterns were similar to those previously observed in Europe, but significantly different from the ones observed in America and Asia due to dissimilarities in source precursor emissions. Nitroaromatic compounds showed higher concentrations in winter due to larger emissions of their precursors originating from biomass combustion used for residential heating purposes. Among the biogenic markers, only isoprene SOA marker concentrations increased in summer while pinene SOA markers did not display any clear seasonal trend. The measured SOA markers, usually considered as semi-volatiles, were mainly associated to the particulate phase, except for the nitrophenols and nitroguaiacols, and their gas/particle partitioning (GPP) showed a low temperature and OM concentrations dependency. An evaluation of their GPP with thermodynamic model predictions suggested that apart from equilibrium partitioning between organic phase and air, the GPP of the markers is affected by processes suppressing volatility from a mixed organic and inorganic phase, such as enhanced dissolution in aerosol aqueous phase and non-equilibrium conditions. SOA marker concentrations were used to apportion secondary organic carbon (SOC) sources applying both, an improved version of the SOA-tracer method and positive matrix factorization (PMF) Total SOC estimations agreed very well between both models, except in summer and during a highly processed Springtime PM pollution event in which systematic underestimation by the SOA tracer method was evidenced. As a first approach, the SOA-tracer method could provide a reliable estimation of the average SOC concentrations, but it is limited due to the lack of markers for aged SOA together with missing SOA/SOC conversion fractions for several sources.

Comparison of five methodologies to apportion organic aerosol sources during a PM pollution event

This study presents a comparison of five methodologies to apportion primary (POA) and secondary organic aerosol (SOA) sources from measurements performed in the Paris region (France) during a highly processed PM pollution event. POA fractions, estimated from EC-tracer method and positive matrix factorization (PMF) analyses, conducted on measurements from PM₁₀ filters, aerosol chemical speciation monitor (ACSM) and offline aerosol mass spectrometry (AMS), were all comparable (2.2-3.7 μg m^-3 as primary organic carbon (POC)). Associated relative uncertainties (measurement + model) on POC estimations ranged from 8 to 50%. The best apportionment of primary traffic OA was achieved using key markers (EC and 1-nitropyrene) in the chemical speciation-based PMF showing more pronounced rush-hour peaks and greater correlation with NO_x than other traffic related POC factors. All biomass burning-related factors were in good agreement, with a typical diel profile and a night-time increase linked to residential heating. If PMF applied to ACSM data showed good agreement with other PMF outputs corrected from dust-related factors (coarse PM), discrepancies were observed between individual POA factors (traffic, biomass burning) and directly comparable SOA factors and highly oxidized OA. Similar secondary organic carbon (SOC) concentrations (3.3 ± 0.1 μg m^-3) were obtained from all approaches, except the SOA-tracer method (1.8 μg m^-3). Associated uncertainties ranged from 14 to 52% with larger uncertainties obtained for PMF-chemical data, EC- and SOA-tracer methods. This latter significantly underestimated total SOA loadings, even including biomass burning SOA, due to missing SOA classes and precursors. None of the approaches was able to identify the formation mechanisms and/or precursors responsible for the highly oxidized SOA fraction associated with nitrate- and/or sulfate-rich aerosols (35% of OA). We recommend the use of a combination of different methodologies to apportion the POC/SOC concentrations/contributions to get the highest level of confidence in the estimates obtained.

Opioid Prescribing Recommendations After Mohs Micrographic Surgery and Reconstruction: A Delphi Consensus

BACKGROUND

Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence.

OBJECTIVE

To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction.

METHODS

This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at ≥80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval.

RESULTS

Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid.

CONCLUSION

Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommendations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic.

Probiotic characterization of bacterial strains from fermented South Indian tomato pickle and country chicken intestine having antioxidative and antiproliferative activities

AIM

The present study aims to evaluate the potential antioxidant and antiproliferative properties of probiotic bacterial isolates Weissella cibaria p3B, Bacillus subtilis CS, and Bacillus tequilensis CL, isolated from South Indian fermented tomato pickle (homemade) and gut content of indigenous country chicken.

METHODS AND RESULTS

The bacterial isolates exhibited antimicrobial activity against food-borne, human pathogenic bacteria, along with better survival under different bile and acidic conditions, hydrophobicity towards several hydrocarbons, and adherence to intestinal epithelial cells (INT-407 cells). Also, the intact cell (IC) mixture of the three species showed better DPPH, ABTS, and Fe²⁺ chelating activity as compared to the individual IC or cell extract (CE) activity. Among the three bacterial species, W. cibaria p3B revealed maximum antiproliferative activity against HeLa and Caco-2 cancer cells, all of which were nontoxic to INT-407 cells. Apart from being non-hemolytic, the bacterial isolates did not display any necrotic inhibition in HeLa and Caco-2 cells. The cell free supernatant (CFS) of the three bacterial isolates were tested for the production of antimicrobial peptides or bacteriocins. It found that the CFS of bacterial isolates was stable at various temperature, pH and sensitive to proteolytic enzymes confirms protenoius in nature of the antimicrobil peptides or bacteriocins.

CONCLUSION

The bacterial isolates showed promising antimicrobial, antioxidant as well as antiproliferative activities with better survival ability at different pH and bile concentrations. The three bacterial isolates were able to produce potential antimicrobial peptides or bacteriocins.

SIGNIFICANCE AND IMPACT OF THE STUDY

These results indicate better compatibility of our bacterial isolates against synthetic drugs to avoid adverse side effects and can be processed as dietary supplements against food and human pathogens. They can also provide antioxidative and antiproliferative benefits to humans and animals.

Evaluation of the relationship between blood cell parameters and vascular calcification in dialysis-dependent end-stage renal disease patients

Coronary artery calcification is an acceptable tool for cardiovascular risk assessment in end-stage renal disease (ESRD) population. We aimed to identify the association and predictive value of components of blood cell parameters with coronary and thoracic aorta vascular calcification (VC) in ESRD population on dialysis. All ESRD patients receiving hemodialysis or peritoneal dialysis aged between 18 and 60 years were included in the study. Exclusion criteria comprised patients with active infection or inflammatory disease, autoimmune disease, congestive heart failure, angina pectoris and/or documented coronary artery disease, thyroid disease, and hepatic dysfunction. Agatston scoring was used for the evaluation of coronary aorta calcification (CAC) score (CACS) and thoracic aorta calcification (TAC) score (TACS). Compared to participants with no VC, those who had VC were statistically significantly older (P <0.001) and had higher neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) (P = 0.02 and <0.001, respectively). On multivariate logistic regression analysis, increasing age (P = 0.00) and higher PLR (P = 0.04) were associated with an increased likelihood of exhibiting VC (CAC or TAC). There was a positive correlation between CACS and age (rs = 0.495, P = 0.00). A statistically significant positive correlation existed between TACS and age (rs = 0.516, P = 0.00). Similarly, a positive correlation was found between NLR, PLR, and TACS (rs = 0.334, P = 0.001, and rs = 0.438, P = 0.00, respectively). On multivariate linear regression analysis, increased age and red cell distribution width were found to be significant predictors of log(n) TACS. PLR of 135 gave a sensitivity of 80% and a specificity of 50% for predicting VC. Being a cost-effective and easily available investigation, the utilization of the correlation of NLR and PLR with CAC and TAC appears promising, particularly in the age group of 30-60 years.