Mohs Surgeons Dominate Cutaneous Reconstructions in Cosmetically and Functionally Sensitive Sites: Medicare Trends From 2013 to 2019.

BACKGROUND: Although dermatologists perform more cutaneous reconstructions than any other specialists for the Medicare population, the perception of dermatologists as surgeons may not be as fully recognized. Mohs surgeons are trained in complex reconstructions of cosmetically and functionally sensitive (CFS) sites, although the proportion they account for is unknown. OBJECTIVE: To quantify the proportion of cutaneous reconstructions in CFS sites performed by Mohs surgeons compared with other specialists, and to identify trends from 2013 to 2019. METHODS: A cross-sectional analysis was performed using the Medicare Public Use Files for 2013 to 2019. Data were stratified by physician specialty, with dermatologists further subdivided into Mohs surgeons and non-Mohs dermatologists. RESULTS: Mohs surgeons performed 75.3% of all reconstructions in 2019, a significant increase from 2013 ( p < .0001). Mohs surgeons dominated nearly every type of CFS cutaneous reconstruction, with significant increases in proportion ( p < .0001) from 2013 to 2019 for every category except interpolation flaps. Complex repairs were the most commonly performed cutaneous reconstruction type. CONCLUSION: Mohs surgeons perform far more cutaneous reconstructive surgeries in CFS sites than any other specialty for the Medicare population, with significant increases in their lead over the study period.

Real-world outcomes of melanoma surveillance using the MoleMap NZ telemedicine platform.

BACKGROUND: MoleMap NZ is a novel New Zealand-based store-and-forward telemedicine service to detect melanoma. It uses expert review of total body photography and close-up and dermoscopic images of skin lesions that are suspicious for malignancy. OBJECTIVE: The purpose of this study was to assess the effectiveness of MoleMap NZ as a melanoma early detection program. METHODS: We conducted a review of 2108 melanocytic lesions recommended for biopsy/excision by MoleMap NZ dermoscopists between January 2015 and December 2016. RESULTS: Pathologic diagnoses were available for 1571 lesions. Of these, 1303 (83%) lesions were benign and 260 (17%) lesions were diagnosed as melanoma, for a melanoma-specific benign:malignant ratio of 5.0:1. The number needed to biopsy to obtain 1 melanoma was 6. Among melanomas with available tumor thickness data (n = 137), 92% were <0.8 mm (range in situ to 3.1 mm), with in situ melanomas comprising 74%. LIMITATIONS: Only lesions recommended for excision were analyzed. Pathology results were available for 75% of these cases. Tumor thickness data were available for 53% of melanomas diagnosed. CONCLUSIONS: This real-world study of MoleMap NZ, a community-based teledermoscopy program, suggests that it has the potential to increase patients' access to specialist expertise via telemedicine. Additional studies are needed to more accurately define its efficacy.

Pulsed electromagnetic fields promote repair of focal articular cartilage defects with engineered osteochondral constructs.

Articular cartilage injuries are a common source of joint pain and dysfunction. We hypothesized that pulsed electromagnetic fields (PEMFs) would improve growth and healing of tissue-engineered cartilage grafts in a direction-dependent manner. PEMF stimulation of engineered cartilage constructs was first evaluated in vitro using passaged adult canine chondrocytes embedded in an agarose hydrogel scaffold. PEMF coils oriented parallel to the articular surface induced superior repair stiffness compared to both perpendicular PEMF (p = .026) and control (p = .012). This was correlated with increased glycosaminoglycan deposition in both parallel and perpendicular PEMF orientations compared to control (p = .010 and .028, respectively). Following in vitro optimization, the potential clinical translation of PEMF was evaluated in a preliminary in vivo preclinical adult canine model. Engineered osteochondral constructs (∅ 6 mm × 6 mm thick, devitalized bone base) were cultured to maturity and implanted into focal defects created in the stifle (knee) joint. To assess expedited early repair, animals were assessed after a 3-month recovery period, with microfracture repairs serving as an additional clinical control. In vivo, PEMF led to a greater likelihood of normal chondrocyte (odds ratio [OR]: 2.5, p = .051) and proteoglycan (OR: 5.0, p = .013) histological scores in engineered constructs. Interestingly, engineered constructs outperformed microfracture in clinical scoring, regardless of PEMF treatment (p < .05). Overall, the studies provided evidence that PEMF stimulation enhanced engineered cartilage growth and repair, demonstrating a potential low-cost, low-risk, noninvasive treatment modality for expediting early cartilage repair.

Technological advances for the detection of melanoma: Advances in diagnostic techniques.

Managing the balance between accurately identifying early stage melanomas while avoiding obtaining biopsy specimens of benign lesions (ie, overbiopsy) is the major challenge of melanoma detection. Decision making can be especially difficult in patients with extensive atypical nevi. Recognizing that the primary screening modality for melanoma is subjective examination, studies have shown a tendency toward overbiopsy. Even low-risk routine surgical procedures are associated with morbidity, mounting health care costs, and patient anxiety. Recent advancements in noninvasive diagnostic modalities have helped improve diagnostic accuracy, especially when managing melanocytic lesions of uncertain diagnosis. Breakthroughs in artificial intelligence have also shown exciting potential in changing the landscape of melanoma detection. In the first article in this continuing medical education series, we review novel diagnostic technologies, such as automated 2- and 3-dimensional total body imaging with sequential digital dermoscopic imaging, reflectance confocal microscopy, and electrical impedance spectroscopy, and we explore the logistics and implications of potentially integrating artificial intelligence into existing melanoma management paradigms.

Technological advances for the detection of melanoma: Advances in molecular techniques.

The growth of molecular technologies analyzing skin cells and inherited genetic variations has the potential to address current gaps in both diagnostic accuracy and prognostication in patients with melanoma or in individuals who are at risk for developing melanoma. In the second article in this continuing medical education series, novel molecular technologies are reviewed. These have been developed as adjunct tools for melanoma management and include the Pigmented Lesion Assay, myPath Melanoma, and DecisionDx-Melanoma tests, and genetic testing in patients with a strong familial melanoma history. These tests are commercially available and marketed as ancillary tools for clinical decision-making, diagnosis, and prognosis. We review fundamental principles behind each test, discuss peer-reviewed literature assessing their performance, and highlight the utility and limitations of each assay. The goal of this article is to provide a comprehensive, evidence-based foundation for clinicians regarding the management of patients with difficult pigmented lesions.

Diagnosis and management of vulvar cancer: A review.

Vulvar malignancies represent a serious gynecologic health concern, especially given the increasing incidence over the past several decades. Squamous cell carcinoma and melanoma are common subtypes, although other neoplasms, such as basal cell carcinoma and Paget disease of the vulva, might be seen. Many vulvar cancers are initially misdiagnosed as inflammatory conditions, delaying diagnosis and worsening prognosis. It is essential that dermatologists are familiar with characteristic findings for each malignancy to ensure appropriate diagnosis and management. Herein, we review the unique epidemiologic and clinical characteristics of each major vulvar malignancy, as well as discuss their respective prognoses and current management recommendations.

Demodex species in human ocular disease: new clinicopathological aspects.

Demodex brevis and Demodex folliculorum are likely ubiquitous organisms associated with human eyelashes. However, they have also been implicated in the pathogenesis of external ocular diseases. This article reviews the current literature in regards to life cycle, morphology, pathogenesis and treatment of underlying Demodex spp. infestation and outlines the previously undescribed in vivo behaviour of the mites. Images were obtained from the epilation of lashes from 404 patients seen in clinical practice. Epilated lashes were placed on a microscope slide which had been coated with optically clear hypromellose/carbomer gel (Genteal gel, Novartis pharmaceuticals corporation, East Hanover, New Jersey). Adults were identified with either dark field or standard transmission microscopy at 40-100×. Eggs and other life-cycle stages were examined at 250× magnification, with transmission microscopy giving the best image resolution. The life cycle of the mite has been reviewed and simplified according to clinical observations. Clinical signs suggestive of underlying Demodex spp. infestation have been described, and their pathogenesis was explained based on the micrographic digital images obtained. The problem of symptomatic Demodex spp. disease likely reflects an imbalance in the external ocular ecology; however, the role of Demodex spp. as a commensal should not be overlooked. Treatment should not be aimed at total eradication of the mite but rather restoring the ocular ecology to a balanced state. By revisiting the life cycle of the mite, we can identify areas where possible intervention may be effective.

Fabrication of tissue engineered osteochondral grafts for restoring the articular surface of diarthrodial joints.

Osteochondral allograft implantation is an effective cartilage restoration technique for large defects (>10 cm(2)), though the demand far exceeds the supply of available quality donor tissue. Large bilayered engineered cartilage tissue constructs with accurate anatomical features (i.e. contours, thickness, architecture) could be beneficial in replacing damaged tissue. When creating these osteochondral constructs, however, it is pertinent to maintain biofidelity to restore functionality. Here, we describe a step-by-step framework for the fabrication of a large osteochondral construct with correct anatomical architecture and topology through a combination of high-resolution imaging, rapid prototyping, impression molding, and injection molding.

Demodex treatment in external ocular disease: the outcomes of a Tasmanian case series.

Demodex species (spp.) have previously been implicated in the pathogenesis of blepharitis. This study aims to correlate improvement in symptoms of external ocular disease with treatment of underlying Demodex spp. This is a prospective, observational case series of patients with chronic external ocular disease. Demodicosis was confirmed by microscopic examination of epilated eyelashes. The main outcome measure was response to the treatment (5 % tee tree oil) in regard to change in subjective symptoms utilising a symptom-based patient questionnaire assessment. Overall patients had a good response to the treatment in terms of improvement or resolution of symptoms, with 91 % of patients reporting at least some improvement in symptoms. The treatment of underlying Demodex spp. appears to result in improvement of symptoms in patients with long standing external ocular disease and underlying Demodex spp. infestation.

In vitro inflammatory multi-cellular model of osteoarthritis.

Objective: Osteoarthritis (OA) is a chronic joint disease, with limited treatment options, characterized by inflammation and matrix degradation, and resulting in severe pain or disability. Progressive inflammatory interaction among key cell types, including chondrocytes and macrophages, leads to a cascade of intra- and inter-cellular events which culminate in OA induction. In order to investigate these interactions, we developed a multi-cellular in vitro OA model, to characterize OA progression, and identify and evaluate potential OA therapeutics in response to mediators representing graded levels of inflammatory severity. Methods: We compared macrophages, chondrocytes and their co-culture responses to "low" Interleukin-1 (IL-1) or "high" IL-1/tumor necrosis factor (IL-1/TNF) levels of inflammation. We also investigated response changes following the administration of dexamethasone (DEX) or mesenchymal stromal cell (MSC) treatment via a combination of gene expression and secretory changes, reflecting not only inflammation, but also chondrocyte function. Results: Inflamed chondrocytes presented an osteoarthritic-like phenotype characterized by high gene expression of pro-inflammatory cytokines and chemokines, up-regulation of ECM degrading proteases, and down-regulation of chondrogenic genes. Our results indicate that while MSC treatment attenuates macrophage inflammation directly, it does not reduce chondrocyte inflammatory responses, unless macrophages are present as well. DEX however, can directly attenuate chondrocyte inflammation. Conclusions: Our results highlight the importance of considering multi-cellular interactions when studying complex systems such as the articular joint. In addition, our approach, using a panel of both inflammatory and chondrocyte functional genes, provides a more comprehensive approach to investigate disease biomarkers, and responses to treatment.

Emotional journey of Asian mothers of premature infants who received pasteurised donor human milk: a qualitative study.

OBJECTIVE: To explore the effect of donor human milk usage on the emotional experience of mothers with premature infants in a multiracial Asian population. DESIGN: A qualitative descriptive study. Semistructured individual interviews were audio-recorded, transcribed and analysed using Braun and Clarke's process of thematic analysis. SETTING AND PATIENTS: Seventeen mothers whose premature infants received donor human milk in a level III neonatal intensive care unit. MAIN OUTCOME MEASURES: Perceptions of mothers whose premature infants received donor human milk. RESULTS: Mothers described their experience as a journey of acceptance with three sequential themes. 'Resistance to receiving somebody else's milk' was a process of overcoming initial hesitation and concerns. 'Recognising maternal limitations and baby's needs' depicted the mothers' struggles in reconciling their infant's milk demand and their low milk supply. 'Embracing benefits of donor human milk and acceptance with gratitude' illustrated the mothers' joy and gratitude to milk donors as they embraced benefits of donor human milk usage. Although participants had agreed to use of donor human milk after counselling, many still struggled with negative emotions of anxiety and guilt. Mothers of Muslim faith had additional concerns about milk kinship and religious permissibility of donor human milk. CONCLUSION: Mothers undergo a spectrum of complex emotions from initial hesitation to acceptance with gratitude, when their premature infants receive donor human milk. Some continue to struggle with negative emotions and require more support. By recognising their emotional responses, healthcare providers can support mothers in their breastfeeding journey with targeted counselling.

Magnetic Levitation System Isolates and Purifies Airborne Viruses.

Detection of viable viruses in the air is critical in order to determine the level of risk associated with the airborne diffusion of viruses. Different methods have been developed for the isolation, purification, and detection of viable airborne viruses, but they require an extensive processing time and often present limitations including low physical efficiency (i.e., the amount of collected viruses), low biological efficiency (i.e., the number of viable viruses), or a combination of all. To mitigate such limitations, we have employed an efficient technique based on the magnetic levitation (Maglev) technique with a paramagnetic solution and successfully identified distinct variations in levitation and density characteristics among bacteria (Escherichia coli), phages (MS2), and human viruses (SARS-CoV-2 and influenza H1N1). Notably, the Maglev approach enabled a significant enrichment of viable airborne viruses in air samples. Furthermore, the enriched viruses obtained through Maglev exhibited high purity, rendering them suitable for direct utilization in subsequent analyses such as reverse transcription-polymerase chain reaction (RT-PCR) or colorimetric assays. The system is portable, easy to use, and cost-efficient and can potentially provide proactive surveillance data for monitoring future outbreaks of airborne infectious diseases and allow for the induction of various preventative and mitigative measures.

Dental dams in dermatology: An underutilized barrier method of protection.

Dental dams are a barrier method of protection, which may help prevent the spread of sexually transmitted infections during oral-vaginal or oral-anal sex. Despite their relative simplicity of use, data on dental dams are limited and patients infrequently utilize this method of barrier protection because of the lack of awareness, perceived barriers to procurement and accessibility, and unfamiliarity on the part of health educators. Nevertheless, increased knowledge of dental dams may be beneficial especially in high-risk populations, where sexually transmitted infections are more common and remain a significant cause for morbidity. This article aims to increase awareness and knowledge of dental dams, as well as provide an informational guide on their procurement and use that may be helpful to dermatologists when counseling patients.

Bioactive glass 13-93 as a subchondral substrate for tissue-engineered osteochondral constructs: a pilot study.

BACKGROUND: Replacement of diseased areas of the joint with tissue-engineered osteochondral grafts has shown potential in the treatment of osteoarthritis. Bioactive glasses are candidates for the osseous analog of these grafts. QUESTIONS/PURPOSES: (1) Does Bioactive Glass 13-93 (BG 13-93) as a subchondral substrate improve collagen and glycosaminoglycan production in a tissue-engineered cartilage layer? (2) Does BG 13-93 as a culture medium supplement increase the collagen and glycosaminoglycan production and improve the mechanical properties in a tissue-engineered cartilage layer? METHODS: In Study 1, bioactive glass samples (n = 4) were attached to a chondrocyte-seeded agarose layer to form an osteochondral construct, cultured for 6 weeks, and compared to controls. In Study 2, bioactive glass samples (n = 5) were cocultured with cell-seeded agarose for 6 weeks. The cell-seeded agarose layer was exposed to BG 13-93 either continuously or for the first or last 2 weeks in culture or had no exposure. RESULTS: Osteochondral constructs with a BG 13-93 base had improved glycosaminoglycan deposition but less collagen II content. Agarose scaffolds that had a temporal exposure to BG 13-93 within the culture medium had improved mechanical and biochemical properties compared to continuous or no exposure. CONCLUSIONS: When used as a subchondral substrate, BG 13-93 did not improve biochemical properties compared to controls. However, as a culture medium supplement, BG 13-93 improved the biochemical and mechanical properties of a tissue-engineered cartilage layer. CLINICAL RELEVANCE: BG 13-93 may not be suitable in osteochondral constructs but could have potential as a medium supplement for neocartilage formation.

Coculture of engineered cartilage with primary chondrocytes induces expedited growth.

BACKGROUND: Soluble factors released from chondrocytes can both enhance and induce chondrocyte-like behavior in cocultured dedifferentiated cells. The ability to similarly prime and modulate biosynthetic activity of differentiated cells encapsulated in a three-dimensional environment is unknown. QUESTIONS/PURPOSES: To understand the effect of coculture on engineered cartilage, we posed three hypotheses: (1) coculturing with a monolayer of chondrocytes ("chondrocyte feeder layer") expedites and increases engineered tissue growth; (2) expedited growth arises from paracrine effects; and (3) these effects are dependent on the specific morphology and expression of the two-dimensional feeder cells. METHODS: In three separate studies, chondrocyte-laden hydrogels were cocultured with chondrocyte feeder layers. Mechanical properties and biochemical content were quantified to evaluate tissue properties. Histology and immunohistochemistry stains were observed to visualize each constituent's distribution and organization. RESULTS: Coculture with a chondrocyte feeder layer led to stiffer tissue constructs (Young's modulus and dynamic modulus) with greater amounts of glycosaminoglycan and collagen. This was dependent on paracrine signaling between the two populations of cells and was directly modulated by the rounded morphology and expression of the feeder cell monolayer. CONCLUSIONS: These findings suggest a potential need to prime and modulate tissues before implantation and present novel strategies for enhancing medium formulations using soluble factors released by feeder cells. CLINICAL RELEVANCE: Determining the soluble factors present in the coculture system can enhance a chondrogenic medium formulation for improved growth of cartilage substitutes. The feeder layer strategy described here may also be used to prime donor cartilage allografts before implantation to increase their success in vivo.