Clinical Acuity Shorthand System: a standardized classification tool to facilitate handoffs.

BACKGROUND: The handoff of medical information from one provider to another can be inefficient and error prone, potentially undermining patient safety. Although several tools for structuring handoffs exist, none provide a brief, standardized framework for ensuring that patient acuity is efficiently and reliably communicated. We aim to introduce and perform initial testing of the Clinical Acuity Shorthand System (CLASS) (Copyright 2015, Duke University. All rights reserved.) for surgery, a patient classification tool intended to facilitate efficient communication of key patient information during handoffs. MATERIALS AND METHODS: Surgical trainees at a single center were asked to perform an exercise involving application of CLASS to 10 theoretical patient scenarios and to then complete a brief survey. Responses were scored based on similarity to target answers. Performance was evaluated overall and between groups of trainees. Time required to complete the exercise was also determined and perceived utility of the system was assessed based on survey responses. RESULTS: The study task was completed by 17 participants. Mean time to task completion was 10.3 ± 8.4 min. Accuracy was not decreased, and was in fact superior, in junior trainees. Most respondents indicated that such a system would be feasible and could prevent medical errors. CONCLUSIONS: CLASS is a novel system that can be learned quickly and implemented readily by trainees and can be used to convey patient information concisely and with acceptable fidelity regardless of level of training. Further study examining application of this system on clinical surgical services is warranted.

Computed Tomography-Based Limb Volume Measurements for Isolated Limb Infusion in Melanoma.

BACKGROUND: Despite advances in cross-sectional imaging, chemotherapeutic dosing for isolated limb infusion (ILI) in melanoma is currently calculated through cumbersome and potentially imprecise manual measurements. The primary objective of this study was to examine the feasibility of using computed tomography (CT) to calculate limb volume, its concordance with manual measurement, and its ability to predict clinical response and toxicity in patients undergoing ILI. METHODS: A retrospective analysis of all patients undergoing lower extremity ILI at Duke University Medical Center between 2003 and 2014 was performed. Data pertaining to manually measured limb volume, chemotherapeutic dosing, and patient outcome was obtained. CT-based measurements of limb volume were performed in all patients for whom imaging was available and subsequently compared with manually measured values. RESULTS: CT data were sufficient for measurement in 73 patients. The mean measurement time was 4.61 ± 2.13 min. Although average CT-based measurements were 1.20 L higher in the case of lower limbs, they correlated well with those obtained manually (r (2) = 0.90). Unlike manual measurement, patients with complete responses to chemotherapy had smaller limb volumes than those with disease progression as measured by CT (9.3 vs. 10.7 L; p = .038). Patients suffering grade 3 and 4 toxicities also had statistically lower limb volumes as measured by CT than those who did not (p < .05). CONCLUSIONS: CT-based limb volume measurement is feasible for chemotherapy dosing in patients undergoing ILI for melanoma and has predictive value with respect to clinical response and toxicity.

Shifting Paradigms in Allergic Contact Dermatitis: The Role of Innate Immunity.

The role of the innate immune system in allergic contact dermatitis (ACD) has traditionally been confined to the initial antigen sensitization phase. However, more recent findings have shown the role of innate immunity in additional aspects of ACD, including the effector phase of the classic type IV hypersensitivity reaction. As a result, the precise immunologic mechanisms mediating ACD are more complex than previously believed. The aim of this review is to provide insight into recent advances in understanding the role of the innate immune system in the pathogenesis of ACD, including novel mechanistic roles for macrophages, innate lymphoid cells, natural killer cells, innate γδ T cells, and other signaling molecules. These insights provide new opportunities for therapeutic intervention in ACD.

The utility of initial staging PET-CT as a baseline scan for surveillance imaging in stage II and III melanoma.

BACKGROUND: This study evaluates the utility of whole-body PET-CT for the initial staging and subsequent surveillance imaging of patients with completely resected stage II and stage III melanoma. METHODS: A single-center, retrospective review of patients who received perioperative whole-body PET-CT from January 1, 2005 to December 1, 2019 within three months of initial melanoma diagnosis was performed. RESULTS: Of 258 total patients with completely resected melanoma who had a PET-CT within 3 months after their melanoma diagnosis, 113 had stage II and 145 had stage III melanoma. PET-CT detected distant metastasis in 3 (2.7%) of 113 stage II patients and 7 (4.8%) of 145 stage III patients. 179 of 258 patients had adequate follow-up time to determine whether they received surveillance cross-sectional imaging and whether they had a melanoma recurrence. 143 (79.9%) received subsequent surveillance imaging, 74 of whom developed a recurrence. In 64 (86.5%) of 74 cases, recurrence was detected by routine surveillance. 26 (34.2%) of 76 stage II and 65 (63.1%) of 103 stage III patients developed a recurrence. The median time to recurrence among the 179 patients for stage II and III was 16.3 and 13.0 months, respectively. CONCLUSIONS: These findings indicate that baseline staging with whole-body PET-CT rarely provides information that changes initial management. Rather, the value of the initial PET-CT is as a baseline for subsequent surveillance scans. Therefore, it may be premature to discourage cross-sectional imaging for patients with stage II and III melanoma without supportive evidence or a reliable biomarker of recurrent disease.

Nanotechnology-based strategies for combating toxicity and resistance in melanoma therapy.

Drug toxicity and resistance remain formidable challenges in cancer treatment and represent an area of increasing attention in the case of melanoma. Nanotechnology represents a paradigm-shifting field with the potential to mitigate drug resistance while improving drug delivery and minimizing toxicity. Recent clinical and pre-clinical studies have demonstrated how a diverse array of nanoparticles may be harnessed to circumvent known mechanisms of drug resistance in melanoma to improve therapeutic efficacy. In this review, we discuss known mechanisms of resistance to various melanoma therapies and possible nanotechnology-based strategies that could be used to overcome these barriers and improve the pharmacologic arsenal available to combat advanced stage melanoma.

Copperhead Envenomation Resulting in a Rare Case of Hand Compartment Syndrome and Subsequent Fasciotomy.

Copperhead bites account for nearly 40% of all snakebites in the United States. Although common, these bites are rarely severe, and most are treated with supportive care and antivenom. We describe the first reported case of a copperhead envenomation resulting in a hand compartment syndrome with measured elevated compartment pressures that necessitated fasciotomy of the hand. Our case underscores the importance of vigilance in the diagnosis and management of copperhead envenomation.

Diagnostic and therapeutic considerations in idiopathic hypereosinophilia with warm autoimmune hemolytic anemia.

Hypereosinophilic syndrome (HES) encompasses numerous diverse conditions resulting in peripheral hypereosinophilia that cannot be explained by hypersensitivity, infection, or atopy and that is not associated with known systemic diseases with specific organ involvement. HES is often attributed to neoplastic or reactive causes, such as chronic eosinophilic leukemia, although a majority of cases remains unexplained and are considered idiopathic. Here, we review the current diagnosis and management of HES and present a unique case of profound hypereosinophilia associated with warm autoimmune hemolytic anemia requiring intensive management. This case clearly illustrates the limitations of current knowledge with respect to hypereosinophilia syndrome as well as the challenges associated with its classification and management.

Sentinel lymph node biopsy following a rotational flap.

Sentinel lymph node biopsy (SLNB) is a critical component of melanoma management. Extensive prior surgery at the site of a primary melanoma is considered a relative contraindication for SLNB. While evidence suggests that SLNB may be performed accurately even in those patients who have undergone prior wide local excision, it is less clear whether patients who have undergone more extensive surgical procedures, particularly flap reconstructions, can benefit from this procedure. We report a case of a patient who had undergone surgical removal of a primary melanoma and subsequent reconstruction with a rotational flap in whom a SLNB was performed successfully, which revealed nodal metastasis, suggesting that SLNB may remain an appropriate option in carefully selected patients who have previously undergone extensive surgery at site of primary disease.