Tranexamic Acid Prevention of Hemorrhagic Complications Following Interpolated Flap Repair: A Single-Center, Retrospective, Cohort Study.

BACKGROUND: Tranexamic acid (TXA) is increasingly being used to prevent hemorrhagic complications after dermatologic surgery. Interpolated flap repairs following Mohs micrographic surgery are at risk for increased bleeding events and unplanned health care utilization, particularly among patients on antithrombotic medication. OBJECTIVE: To assess bleeding events after interpolated flap repair in patients receiving TXA compared with those who did not. MATERIALS AND METHODS: A retrospective review identified interpolated flap repairs in a 5-year period. Hemorrhagic complications were analyzed, defined as major bleeding events, which included all unplanned medical visits, and minor bleeding events, which included any unplanned patient phone calls or messages through electronic medical record. RESULTS: One hundred fifteen patients had interpolated flap repair during the 5-year period, of which 21 (18.3%) received TXA postprocedure. Twenty-seven bleeding events were identified in the non-TXA group compared with 1 event in the TXA-treated group. Patients who received TXA were less likely to have had a bleeding event (28.7% vs 4.8%, p < .01). CONCLUSION: Patients undergoing interpolation flap repair were less likely to experience a bleeding event after subcutaneous injection of TXA.

Update on Biometry and Lens Calculation - A Review of the Basic Principles and New Developments. / Update Biometrie und Linsenberechnung ­ ein Review zu Grundlagen und neuen Entwicklungen.

These days, accurate calculation of artificial lenses is an important aspect of patient management. In addition to the classic theoretical optical formulae there are a number of new approaches, most of which are available as online calculators. This review aims to explain the background of artificial lens calculation and provide an update on study results based on the latest calculation approaches. Today, optical biometry provides the computational basis for theoretical optical formulae, ray tracing, and also empirical approaches using artificial intelligence. Manufacturer information on IOL design and IOL power recorded as part of quality control could improve calculations, especially for higher IOL powers. With modern measurement data, there is further potential for improvement in the determination of the axial length to the retinal pigment epithelium and by adopting a sum-of-segment approach. With the available data, the cornea can be assumed to be a thick lens. The Kane formula, the EVO 2.0 formula, the Castrop formula, the PEARL-DGS, formula and the OKULIX calculation software provide consistently good results for artificial lens calculations. Excellent refractive results can be achieved using these tools, with approximately 80% having an absolute prediction error within 0.50 dpt, at least in highly selected study populations. The Barrett Universal II formula also produces excellent results in the normal and long axial length range. For eyes with short axial lengths, the use of Barrett Universal II should be reconsidered; in this case, one of the methods mentioned above is preferable. Second Eye Refinement can also be considered in this patient population, in conjunction with established classic third generation formulae.

Biometry and Intraocular Lens Power Calculation in Eyes with Prior Laser Vision Correction (LVC) - A Review.

BACKGROUND: An intraocular lens (IOL) calculation in eyes that have undergone laser vision correction (LVC) poses a significant clinical issue in regards to both patient expectation and accuracy. This review aims to describe the pitfalls of IOL power calculation after LVC and give an overview of the current methods of IOL power calculation after LVC. REVIEW: Problems after LVC derive from the measurement of anterior corneal radii, central corneal thickness, asphericity, and the predicted effective lens position. A central issue is that most conventional 3rd generation formulas estimate lens position amongst other parameters on keratometry, which is altered in post-LVC eyes. CONCLUSION: An IOL power calculation results in eyes with prior LVC that are notably impaired in eyes without prior surgery. Effective corneal power including anterior corneal curvature, posterior corneal curvature, CCT (central corneal thickness), and asphericity is essential. Total keratometry in combination with the Barrett True-K, EVO (emmetropia verifiying optical formula), or Haigis formula is relatively uncomplicated and seems to provide good results, as does the Barrett True-K formula with anterior K values. The ASCRS ( American Society of Cataract and Refractive Surgery) calculator combines results of various formulae and averages results, which allows a direct comparison between the different methods. Tomography-based raytracing and the Kane and the Castrop formulae need to be evaluated by future studies.

Patient Experience Surveys Reveal Gender-Biased Descriptions of Their Care Providers.

Patient experience surveys (PES) are collected by healthcare systems as a surrogate marker of quality and published unedited online for the purpose of transparency, but these surveys may reflect gender biases directed toward healthcare providers. This retrospective study evaluated PES at a single university hospital between July 2016 and June 2018. Surveys were stratified by overall provider rating and self-identified provider gender. Adjectives from free-text survey comments were extracted using natural language processing techniques and applied to a statistical machine learning model to identify descriptors predictive of provider gender. 109,994 surveys were collected, 17,395 contained free-text comments describing 687 unique providers. The mean overall rating between male (8.84, n = 8558) and female (8.80, n = 8837) providers did not differ (p = 0.149). However, highly-rated male providers were more often described for their agentic qualities using adjectives such as "informative," "forthright," "superior," and "utmost" (OR 1.48, p < 0.01)-whereas highly-rated female providers were more often described by their communal qualities through adjectives such as "empathetic," "sweet," "warm," "attentive," and "approachable" (OR 2.11, p < 0.0001). PES may contain gender stereotypes, raising questions about their impact on physicians and their validity as a quality metric which must be balanced with the need for unedited transparency. Future prospective studies are needed to further characterize this trend across geographically and racially diverse healthcare providers.

Wearing the wolf skin: psychiatry and the phenomenon of the berserker in medieval Scandinavia.

This paper examines the berserker, a frenzied warrior attested to in both the written and material sources of medieval Scandinavia, and elucidates the characteristics that define him. It critiques explanations for the phenomenon offered in the existing historiography and whether this can be explained as a psychiatric diagnosis. It concludes that the berserker cannot be simply defined as a culturally bound or other psychiatric syndrome, or accounted for by psychogenic drugs alone. Instead, it proposes that berserk frenzy constituted a transitory dissociative state shared among a small warband steeped in religious/spiritual ideology. In entering this state, the psyche of the berserker was reconstituted in an almost archetypal pattern. Further research is required into this phenomenon in other contexts, including modern conflicts.

The effect of viral plasticity on the persistence of host-virus systems.

Phenotypic plasticity plays an important role in the survival of individuals. In microbial host-virus systems, previous studies have shown the stabilizing effect that host plasticity has on the coexistence of the system. By contrast, it remains uncertain how the dependence of the virus on the metabolism of the host (i.e. "viral plasticity") shapes bacteria-phage population dynamics in general, or the stability of the system in particular. Moreover, bacteria-phage models that do not consider viral plasticity are now recognised as overly simplistic. For these reasons, here we focus on the effect of viral plasticity on the stability of the system under different environmental conditions. We compared the predictions from a standard bacteria-phage model, which neglects plasticity, with those of a modification that includes viral plasticity. We investigated under which conditions viral plasticity promotes coexistence, with or without oscillatory dynamics. Our analysis shows that including viral plasticity reveals coexistence in regions of the parameter space where models without plasticity predict a collapse of the system. We also show that viral plasticity tends to reduce population oscillations, although this stabilizing effect is not consistently observed across environmental conditions: plasticity may instead reinforce dynamic feedbacks between the host, the virus, and the environment, which leads to wider oscillations. Our results contribute to a deeper understanding of the dynamic control of bacteriophage on host populations observed in nature.

Invasive Melanoma and Melanoma in Situ Treated With Modified Mohs Micrographic Surgery With En Face Permanent Sectioning: A 10-Year Retrospective Review.

BACKGROUND: Successful surgical treatment of cutaneous melanoma is dependent on margin control. OBJECTIVE: To determine efficacy of modified Mohs micrographic surgery (mMMS) with en face permanent margins in management of invasive melanoma (IM) and melanoma in situ (MIS). METHODS: A retrospective cohort study evaluating local recurrence, 5-year recurrence-free survival, and 5-year melanoma-specific survival. Overall, 657 melanomas (128 IM and 529 MIS) from 631 patients were treated using mMMS during a 10-year period. Follow-up information was obtained from medical records and telephone encounters. RESULTS: The median follow-up time was 5.18 years. Most melanomas were located on the head and neck 93.6% (615/657). Margins required for clearance were 0.77 ± 0.44 cm (mean ± SD). Local recurrence was identified in 1.98% (13/657) of melanomas with no local recurrences in IM. Five-year local recurrence-free and melanoma-specific survival rates were estimated to be 96.9% (95% confidence interval [CI]: 94.6%-98.2%) and 99.0% (95% CI: 97.7%-99.6%). There were 5 melanoma-related deaths. CONCLUSION: Modified Mohs micrographic surgery is an effective treatment of melanoma as evidenced by low local recurrence rates and high melanoma-specific survival.

Carcinoma Erysipeloides From Metastatic Cutaneous Squamous Cell Carcinoma Initially Mistaken for Intralymphatic Histiocytosis.

Intralymphatic histiocytosis is a rare dermatologic disorder, commonly associated with inflammatory disorders and rarely malignancy. Carcinoma erysipeloides (CE) is a rare pseudoinflammatory cutaneous eruption that resembles soft -tissue infections as result of intralymphatic metastasis and subsequent lymphatic obstruction. Breast carcinoma represents most of the CE cases, but rarely other malignancies are involved. This report discusses a patient with a history of cutaneous squamous cell carcinoma (SCC) of the temple, who was initially diagnosed with intralymphatic histiocytosis located on his upper extremity, resistant to treatment. Further dermatologic and pathologic review later revealed metastatic SCC restricted to the dermal lymphatics, creating a CE reaction, initially obscured by intralymphatic histiocytes. This case highlights the difficulty in diagnosing metastatic carcinoma when the malignant cells are accompanied by a dense histiocytic infiltrate. The case demonstrates a rare presentation of CE due to metastatic cutaneous SCC and highlights the need for persistent investigation when confronted with nonconforming pathology.

Spontaneous involution (regression) of a solitary cutaneous myofibroma in an adult patient.

Myofibromas are unusual benign tumors most commonly seen in infant children. Clinical involution of the tumor often occurs within the first few years of life. Solitary cutaneous myofibroma is the synonymous adult counterpart of infantile myofibromatosis. Although solitary myofibromas have been reported in patients of all ages, only the infantile variant is believed to regress spontaneously. There are only a few case reports of adolescent and young adult patients with regressing solitary lesions that have been described in the literature to date. We report a 71-year-old male with spontaneous regression of solitary cutaneous myofibroma. The residual lesion was excised and to date has not recurred. This report describes the historical, clinical and histopathological features of adult myofibromas and a novel manifestation that may guide future clinical considerations when approaching solitary tumors with regressive features.

Impact of Gene Expression Profiling on Decision-Making in Clinically Node Negative Melanoma Patients after Surgical Staging.

INTRODUCTION: The surgeon's role in the follow-up of pathologic stage I and II melanoma patients has traditionally been minimal. Melanoma genetic expression profile (GEP) testing provides binary risk assessment (Class 1-low risk, Class 2-high risk), which can assist in predicting metastasis and formulating appropriate follow up. We sought to determine the impact of GEP results on the management of clinically node negative cutaneous melanoma patients staged with sentinel lymph node biopsy (SLNB). METHODS: A retrospective review of prospectively gathered data consisting of patients seen from September 2015 - August 2016 was performed to determine whether GEP class influenced follow-up recommendations. Patients were stratified into four groups based on recommended follow-up plan: Dermatology alone, Surgical Oncology, Surgical Oncology with recommendation for adjuvant clinical trial, or Medical and Surgical Oncology. RESULTS: Of ninety-one patients, 38 were pathologically stage I, 42 stage II, 10 stage III, and 1 stage IV. Combining all stages, GEP Class 1 patients were more likely to be followed by Dermatology alone and less like to be followed by Surgical Oncology with recommendation for adjuvant trial compared to Class 2 patients (P less than 0.001). Among stage 1 patients, Class 1 were more likely to follow up with Dermatology alone compared to Class 2 patients (82 vs. 0%; P less than 0.001). Among stage II patients, GEP Class 1 were more likely to follow up with Dermatology alone (21 vs 0%) and more Class 2 patients followed up with surgery and recommendations for adjuvant trial (36 vs 64%; P less than 0.05). There was no difference in follow up for stage III patients based on the GEP results (P=0.76). CONCLUSION: GEP results were significantly associated with the management of stage I-II melanoma patients after staging with SLNB. For node negative patients, Class 2 results led to more aggressive follow up and management. J Drugs Dermatol. 2018;17(2):196-199.

Seasonal copepod lipid pump promotes carbon sequestration in the deep North Atlantic.

Estimates of carbon flux to the deep oceans are essential for our understanding of global carbon budgets. Sinking of detrital material ("biological pump") is usually thought to be the main biological component of this flux. Here, we identify an additional biological mechanism, the seasonal "lipid pump," which is highly efficient at sequestering carbon into the deep ocean. It involves the vertical transport and metabolism of carbon rich lipids by overwintering zooplankton. We show that one species, the copepod Calanus finmarchicus overwintering in the North Atlantic, sequesters an amount of carbon equivalent to the sinking flux of detrital material. The efficiency of the lipid pump derives from a near-complete decoupling between nutrient and carbon cycling­a "lipid shunt," and its direct transport of carbon through the mesopelagic zone to below the permanent thermocline with very little attenuation. Inclusion of the lipid pump almost doubles the previous estimates of deep-ocean carbon sequestration by biological processes in the North Atlantic.

Projected impacts of 21st century climate change on diapause in Calanus finmarchicus.

Diapause plays a key role in the life cycle of high latitude zooplankton. During diapause, animals avoid starving in winter by living in deep waters where metabolism is lower and met by lipid reserves. Global warming is therefore expected to shorten the maximum potential diapause duration by increasing metabolic rates and by reducing body size and lipid reserves. This will alter the phenology of zooplankton, impact higher trophic levels and disrupt biological carbon pumps. Here, we project the impacts of climate change on the key North Atlantic copepod Calanus finmarchicus under IPCC RCP 8.5. Potential diapause duration is modelled in relation to body size and overwintering temperature. The projections show pronounced geographic variations. Potential diapause duration reduces by more than 30% in the Western Atlantic, whereas in the key overwintering centre of the Norwegian Sea it changes only marginally. Surface temperature rises, which reduce body size and lipid reserves, will have a similar impact to deep-water changes on diapause in many regions. Because deep-water warming lags that at the surface, animals in the Labrador Sea could offset warming impacts by diapausing in deeper waters. However, the ability to control diapause depth may be limited.

Understanding patterns and processes in models of trophic cascades.

Climate fluctuations and human exploitation are causing global changes in nutrient enrichment of terrestrial and aquatic ecosystems and declining abundances of apex predators. The resulting trophic cascades have had profound effects on food webs, leading to significant economic and societal consequences. However, the strength of cascades-that is the extent to which a disturbance is diminished as it propagates through a food web-varies widely between ecosystems, and there is no formal theory as to why this should be so. Some food chain models reproduce cascade effects seen in nature, but to what extent is this dependent on their formulation? We show that inclusion of processes represented mathematically as density-dependent regulation of either consumer uptake or mortality rates is necessary for the generation of realistic 'top-down' cascades in simple food chain models. Realistically modelled 'bottom-up' cascades, caused by changing nutrient input, are also dependent on the inclusion of density dependence, but especially on mortality regulation as a caricature of, e.g. disease and parasite dynamics or intraguild predation. We show that our conclusions, based on simple food chains, transfer to a more complex marine food web model in which cascades are induced by varying river nutrient inputs or fish harvesting rates.

Elevated fish densities extend kilometres from oil and gas platforms.

Thousands of offshore oil and gas platforms have been installed throughout the world's oceans and more structures are being installed as part of the transition to renewable energy. These structures increase the availability of ecological niches by providing hard substrate in midwater and complex 3D habitat on the seafloor. This can lead to 'hotspots' of biodiversity, or increased densities of flora and fauna, which potentially spill over into the local area. However, the distances over which these higher densities extend (the 'range of influence') can be highly variable. Fish aggregate at such structures, but the range of influence and any implications for wider fish populations, are unclear. We investigated the relationship between fish and platform areal densities using high resolution fisheries acoustic data. Data were collected in the waters surrounding the vessel exclusions zones around 16 oil and gas platforms in the North Sea, and throughout the wider area. We estimated densities of schooling fish using echo-integration, and densities of non-schooling fish using echo-counting. At 10 platforms, non-schooling fish densities were elevated near the platform relative to background levels in the equivalent wider area. The range of influence, defined here as the range to which fish densities were elevated above background, varied from 0.8 to 23 km. In areas of high platform density, fish schools were encountered more often, and non-schooling fish densities were higher, when controlling for other sources of environmental variation. This is the first time such long-range effects have been identified; previously, ranges of influence have been reported in the order of just 10s-100s of metres. These findings suggest that the environmental impact of these structures may extend further than previously thought, which may be relevant in the context of upcoming management decisions around the decommissioning of these structures.

DAnCER: disease-annotated chromatin epigenetics resource.

Chromatin modification (CM) is a set of epigenetic processes that govern many aspects of DNA replication, transcription and repair. CM is carried out by groups of physically interacting proteins, and their disruption has been linked to a number of complex human diseases. CM remains largely unexplored, however, especially in higher eukaryotes such as human. Here we present the DAnCER resource, which integrates information on genes with CM function from five model organisms, including human. Currently integrated are gene functional annotations, Pfam domain architecture, protein interaction networks and associated human diseases. Additional supporting evidence includes orthology relationships across organisms, membership in protein complexes, and information on protein 3D structure. These data are available for 962 experimentally confirmed and manually curated CM genes and for over 5000 genes with predicted CM function on the basis of orthology and domain composition. DAnCER allows visual explorations of the integrated data and flexible query capabilities using a variety of data filters. In particular, disease information and functional annotations are mapped onto the protein interaction networks, enabling the user to formulate new hypotheses on the function and disease associations of a given gene based on those of its interaction partners. DAnCER is freely available at http://wodaklab.org/dancer/.

Basal Cell Carcinoma.

Basal cell carcinoma (BCC) is the most common cancer worldwide. Early identification can be made clinically, aided by dermoscopy, in addition to newer imaging technologies such as reflectance confocal microscopy. BCC most commonly demonstrates an indolent course responsive to local destruction or surgical removal. Mohs micrographic surgery is the most effective treatment, especially for high-risk tumors. Low-risk tumors may be amendable to nonsurgical treatment including topical and destructive therapies. Radiation therapy can be used in patients not amendable to surgery. Advanced and metastatic BCC can be treated with Hedgehog pathway inhibitors and other systemic agents with varying responses.

Successful Medical and Surgical Management of Recalcitrant Acanthamoeba Keratitis, Scleritis, and Culture-Positive Scleral Abscess.

PURPOSE: The purpose of this study was to describe the management of a case of recurrent scleritis and Acanthamoeba -positive scleral abscess in a patient after the use of miltefosine for recalcitrant Acanthamoeba keratitis. METHODS: This is a case study. RESULTS: In this study, we report a case of advanced Acanthamoeba keratitis with resultant corneal perforation with therapeutic keratoplasty and associated scleritis who later developed a scleral abscess after treatment with oral miltefosine. The scleral abscess was positive for Acanthamoeba cysts and trophozoites, and after treatment for an additional several months, the patient had complete resolution of her disease. CONCLUSIONS: Acanthamoeba scleritis is a rare complication associated with Acanthamoeba keratitis. It has traditionally been treated as an immune reaction and associated inflammation, especially with the use of miltefosine. Management can require a multitude of different approaches, and in this situation, it has been demonstrated that scleritis can be infectious and that conservative management can be effective.

Characteristics associated with blindness or visual impairment within the adolescent demographic: a national cohort analysis.

BACKGROUND: Psychosocial metrics associated with self-reported blindness or visual impairment for adolescents in the National Survey of Drug Use and Health (NSDUH) have not been fully characterized. This retrospective cohort analysis of the latest NSDUH aimed to determine novel characteristics associated with self-reported visual loss among adolescents in the United States. METHODS: Data from the NSDUH2020, a publicly available, federally validated database, were analyzed. Self-reported severe visual impairment or blindness was defined as being truly blind or having serious difficulty seeing even when wearing corrective lenses (s-rSVI). Inclusion criteria were all cases of s-rSVI in adolescents aged 12-17 years. NSDUH weights were used to accommodate complex survey design, nonresponse rates, and population variance. Weighted percentages, asymptotic two-sided Rao-Scott χ2 analyses, and multivariable logistic regression were performed. Statistical significance was considered reached at P < 0.05. RESULTS: A total of 5,667 adolescents aged 12-17 years were surveyed, and s-rSVI occurred in 236 cases (weighted percentage, 3.48%). Within our final multivariable risk model, characteristics associated with increased odds of s-rSVI were female sex, Asian and Latino race/ethnicity (relative to non-Hispanic White), and self-reported serious difficulty hearing and concentrating (all P < 0.05). CONCLUSIONS: This national retrospective cohort analysis highlights risk factors associated with s-rSVI for adolescents within the 2020 NSDUH. Clinicians and policymakers should consider at-risk demographics for s-rSVI during development and enhancement of screening programs, population health initiatives, and healthcare policy issues.