Melanomas of the head and neck have high-local recurrence risk features and require tissue-rearranging reconstruction more commonly than basal cell carcinoma and squamous cell carcinoma: A comparison of indications for microscopic margin control prior to reconstruction in 13,664 tumors.

BACKGROUND: On the basis of high-local recurrence risk features and tissue-rearranging reconstruction, consensus guidelines recommend microscopic margin control for keratinocyte carcinomas (KCs) but not for cutaneous melanoma. OBJECTIVE: To compare high-local recurrence risk features and frequency of tissue-rearranging reconstruction for head and neck KC with those for melanoma. METHODS: Retrospective cohort study of KC versus melanoma treated at the Hospital of the University of Pennsylvania with Mohs micrographic surgery. RESULTS: A total of 12,189 KCs (8743 basal cell carcinomas and 3343 squamous cell carcinomas) and 1475 melanomas (1065 melanomas in situ and 410 invasive melanomas) were identified from a prospectively updated Mohs micrographic surgery database. Compared with KCs, melanomas were significantly more likely to have high-local recurrence risk features, including larger preoperative size (2.10 cm vs 1.30 cm [P < .0001]), recurrent status (5.08% vs 3.91% [P = .031]), and subclinical spread (31.73% vs 26.52% [P < .0001]). Tissue-rearranging reconstruction was significantly more common for melanoma than for KCs (44.68% vs 33.02% [P < .0001]; odds ratio, 1.98 [P < .0001]). LIMITATIONS: This was a retrospective study, and it did not compare outcomes with those of other treatment methods, such as slow Mohs or conventional excision. CONCLUSION: Melanomas of the head and neck have high-local recurrence risk features and require tissue-rearranging reconstruction more frequently than KCs do.

Intrasubunit V-Y Muscle Sling Myocutaneous Island Advancement Flap for Small Defects Isolated to the Nasal Ala.

BACKGROUND: The V-Y island advancement flap is a useful reconstruction technique for nasal alar defects, but flap mobility is limited by the insertion of the muscles of facial expression into the dermis of the alae. OBJECTIVE: To describe a V-Y muscle sling myocutaneous island advancement flap (SMIAF) for improved mobility and intrasubunit reconstruction of alar defects. MATERIALS AND METHODS: A retrospective review of patient records and preoperative and postoperative photographs was performed on all patients with alar defects repaired with the SMIAF between April 2008 and October 2017. Patients and physicians rated aesthetic outcomes with the Patient and Observer Scar Assessment Scale (POSAS). RESULTS: A total of 18 nasal alar defects were repaired with the SMIAF after Mohs micrographic surgery. All defects were located on the anterior two-thirds of the alar lobule and had a mean surface area of 0.42 ± 0.19 cm. No patients experienced flap necrosis. Patients and 3 independent dermatologic surgeons rated favorable aesthetic outcomes. CONCLUSION: The SMIAF is a reliable reconstruction option with good aesthetic outcomes for small defects on the anterior two-thirds of the nasal ala.

Increased topical generic prices by manufacturers.

BACKGROUND: There is limited data regarding generic medication prices. Recent studies have shown price changes at the retail level, but much is not known about the pharmaceutical supply chain or price changes at the manufacturer level. OBJECTIVE: We sought to examine the extent of price changes for topical generic medications. METHODS: A comprehensive review of average wholesale prices (AWPs) and manufacturers of topical generics and available corresponding branded medications was conducted for 2005 and 2016. RESULTS: A total of 51 topical chemical entities were examined. Between 2005 and 2016, the AWP of topical generic medications increased by 273% and the AWP of topical branded medications increased by 379%. The topical generic with the greatest price change increased by 2529%. Eight of the top 20 topical generic medications with the greatest increases in AWP also had an increase in the number of manufacturers. LIMITATIONS: These findings are not generalizable to medications used in other areas of medicine. CONCLUSION: Topical generic prices are rapidly increasing at the manufacturer level.

Complex Subunit Repair of a Cheek, Nose, and Medial Canthal Defect: A Stepwise Approach.

A recent national survey suggests that up to one-third of facial reconstructive and plastic surgeons do not adhere to the classical principle of subunit reconstruction. While single-stage flaps and grafts may be easier and less time consuming, they can also lead to a poor cosmetic outcome. Here, the authors describe how the authors repaired a complex post-Mohs surgery facial defect involving multiple cosmetic subunits and how adherence to the subunit principle was essential to obtaining the most optimal functional and esthetic outcome.

Cryoplasty for the treatment of coronary bifurcation stenoses following main vessel stenting.

OBJECTIVES: This retrospective study sought to assess the safety and clinical efficacy of cryoplasty for treatment of side-branch stenoses following main vessel stenting in coronary bifurcation lesions. BACKGROUND: Cryoplasty prevents restenosis by reducing smooth muscle proliferation and extracellular matrix synthesis. Clinical effectiveness has been demonstrated in the peripheral circulation. Treatment of coronary bifurcation lesions remains a challenge. We used a novel strategy of main vessel stenting combined with side-branch cryoplasty to treat high-grade stenoses following main vessel stenting. METHODS: Eighteen patients with bifurcation lesions had significant plaque shift into a side branch after main vessel intervention. Drug-eluting stents were placed in the main vessel and cryoplasty was performed on the side-branch vessel. Quantitative coronary analysis was performed on all side-branch vessels both pre- and post-main vessel stenting. All patients had clinical follow-up 3 months or more after cryoplasty including either nuclear stress testing or diagnostic coronary angiogram. RESULTS: Mean percent stenosis decreased from 80.6% post main vessel stenting to 24.8% following cryoplasty (P < 0.0001). Of the 17 patients who had pre-cryoplasty nuclear stress testing 1 patient had ischemia identified in the distribution of the treated vessel at follow-up. Five patients had follow up angiography. One patient had restenosis, the other 2 were unchanged. There was a low incidence of MACE. CONCLUSIONS: In this first report of its use in the coronary circulation, cryoplasty for bifurcation side-branch disease was safe and associated with a low rate of clinical recurrence in carefully selected patients.

How do drivers mitigate the effects of naturalistic visual complexity? : On attentional strategies and their implications under a change blindness protocol.

How do the limits of high-level visual processing affect human performance in naturalistic, dynamic settings of (multimodal) interaction where observers can draw on experience to strategically adapt attention to familiar forms of complexity? In this backdrop, we investigate change detection in a driving context to study attentional allocation aimed at overcoming environmental complexity and temporal load. Results indicate that visuospatial complexity substantially increases change blindness but also that participants effectively respond to this load by increasing their focus on safety-relevant events, by adjusting their driving, and by avoiding non-productive forms of attentional elaboration, thereby also controlling "looked-but-failed-to-see" errors. Furthermore, analyses of gaze patterns reveal that drivers occasionally, but effectively, limit attentional monitoring and lingering for irrelevant changes. Overall, the experimental outcomes reveal how drivers exhibit effective attentional compensation in highly complex situations. Our findings uncover implications for driving education and development of driving skill-testing methods, as well as for human-factors guided development of AI-based driving assistance systems.

Multi3Generation: Multitask, Multilingual, and Multimodal Language Generation.

The article emphasizes the critical importance of language generation today, particularly focusing on three key aspects: Multitasking, Multilinguality, and Multimodality, which are pivotal for the Natural Language Generation community. It delves into the activities conducted within the Multi3Generation COST Action (CA18231) and discusses current trends and future perspectives in language generation.

The Multi3Generation COST Action is a collaborative project that brings together researchers from various fields, all centered around Natural Language Generation. Natural Language Generation involves using computers to generate human-like language for tasks such as translation, summarization, question-answering, and dialogue interaction, among others. The Action addresses common challenges including efficient information representation, advanced machine learning techniques, managing uncertainty in human-Natural Language Generation interactions, and using structured knowledge from diverse sources like databases, images, and videos. Its overarching goal is to make NLG beneficial to society and widely accessible by fostering collaboration between industry and academic experts. Structured into five working groups, the Action focuses on specific aspects of Natural Language Generation, such as understanding and generating different types of information, developing efficient machine learning algorithms, enhancing dialogue and conversational language generation using knowledge bases, and fostering industry collaboration and end-user engagement. With over 133 scientists from 34 countries involved, spanning disciplines from computer science to linguistics, the project promotes diversity and inclusivity, with 60% male and 40% female participants. Relevant businesses like Unbabel and JabberBrain and other AI stakeholders like the Center for Responsible AI contribute to the Action, aiming to have a broader European impact. The Multi3Generation Action prioritizes three main areas: Multitasking, Multilinguality, and Multimodality, aiming to enhance language generation in these domains to support underrepresented languages and meet diverse user needs. The article provides insights into the initiatives and planned activities of Multi3Generation, offering valuable information for those interested in NLG and shedding light on future perspectives in this field.

Cutaneous Sarcomas.

Cutaneous sarcomas are rare malignancies that may present with a variety of clinical manifestations. This article focuses on 4 of the most common cutaneous sarcomas (Kaposi sarcoma, cutaneous angiosarcoma, dermatofibrosarcoma protuberans, and cutaneous leiomyosarcoma) and reviews clinical, diagnostic, and therapeutic aspects of these rare skin malignancies.

The role of income and race/ethnicity in experiences with medical care in the United States and United Kingdom.

Inequalities in experiences with medical care are well-known in the United States, but little is known about the shape of such inequalities in other countries. This study compares a broad spectrum of experiences in the United States and United Kingdom. Furthermore, it focuses on two of the most important dimensions of inequality, race/ethnicity and income, and two of the most widely discussed system-level factors, health insurance and emphasis on primary care. Two general conclusions are reached. First, there are broad income-based inequalities in medical care in both the United States and United Kingdom. These inequalities persist even after controlling for health insurance, including private medical insurance in the United Kingdom. Race is also related to experiences with medical care, although the effects of race are more particular and contingent than are those for income. In particular, the mapping of racial/ethnic inequality differs considerably between the United States and United Kingdom, reflecting their different sociocultural climates. Second, the health care system, especially primary care, plays a limited role in ameliorating inequalities in care, but plays a strong role in elevating the average level of quality within a country. Because inequalities in medical care reflect broader social processes, they are durable across very different health care systems and contexts.

The diagnostic and prognostic value of ECG-gated SPECT myocardial perfusion imaging.

Since the development of gated SPECT imaging approximately 10 y ago, this technique is now almost universally used as an adjunct for radionuclide perfusion imaging, enabling the assessment of perfusion along with determination of regional and global left ventricular function in the same examination. The gated SPECT determination of the left ventricular ejection fraction and volumes has been extensively validated. Additionally, this method allows for the improved identification of soft-tissue artifacts and enhances the detection of multivessel coronary artery disease. Furthermore, gated SPECT provides powerful information for the risk assessment of patients with known or suspected coronary artery disease and aids in the assessment of myocardial viability. Gated SPECT imaging has clearly become an integral part of radionuclide myocardial perfusion imaging.

Thermal analysis of some novel pyrimidine derivatives / Análisis térmico de algunos nuevos derivados de pirimidina

SUMMARY Some new pyrimidine derivatives have been synthesized and their decomposition characteristics have been studied by thermogravimetric and differential scanning calorimetric analysis. The thermal stability and some kinetics parameters of decomposition were evaluated from thermograms. It is observed that depending upon the structure, substitutions, thermal stability and decomposition kinetics varies in different compounds.

RESUMEN Se sintetizaron algunos nuevos derivados de pirimidina y se estudiaron sus características de descomposición mediante análisis termogravimétrico y calorimétrico diferencial de barrido. La estabilidad térmica y algunos parámetros cinéticos de descomposición se evaluaron a partir de los respectivos termogramas. Se observa que, dependiendo de la estructura y las sustituciones, la estabilidad térmica y la cinética de descomposición varían entre los diferentes compuestos.

Effects and mechanisms of left ventricular false tendons on functional mitral regurgitation in patients with severe cardiomyopathy.

OBJECTIVE: False tendons in the left ventricle are commonly observed. Preliminary observations associate false tendons with less functional mitral regurgitation. METHODS: Echocardiograms demonstrating severe cardiomyopathy (ejection fraction < or =30%) were retrospectively examined for left ventricular false tendons. The ejection fraction, cause of left ventricular systolic dysfunction, left ventricular diastolic dimensions, severity of mitral regurgitation, mitral annular diameter, mitral valve coaptation depth, mitral valve coaptation area, and orientation of false tendon were evaluated. The patients with false tendons were compared with a control group with cardiomyopathy without false tendons. RESULTS: A cohort of patients (n = 82) with severe left ventricular systolic dysfunction (mean ejection fraction, 21%) and false tendons were compared with a control group with similar left ventricular dysfunction and no false tendons (n = 121; mean ejection fraction, 20%; P = .10). The patients with false tendons had similar left ventricular diastolic internal dimensions compared with the control group (5.99 and 6.18 cm, respectively; P = .086). Yet patients with false tendons had a very low incidence of severe functional mitral regurgitation compared with the control group (4.9% vs 27%, P < .001). Patients with false tendons had significantly smaller mitral annular diameters (3.57 vs 4.03 cm, P < .001), shorter mitral valve coaptation depths (0.89 vs 1.24 cm, P < .001), and reduced coaptation areas (1.61 vs 2.52 cm(2), P < .001) than the control group. The reduction of mitral regurgitation was more significant for patient with transverse midcavity false tendons. CONCLUSIONS: Patients with false tendons and cardiomyopathy have less severe mitral regurgitation. The mechanism for the reduction in functional mitral regurgitation might be less mitral valve deformation, specifically lower coaptation depth and coaptation area when a false tendon is present.

Management of failed thrombolysis after acute myocardial infarction: an overview of current treatment options.

Thrombolytic therapy remains the most commonly administered revascularization strategy for patients with ST-elevation myocardial infarctions (STEMI). However, many patients fail to have patent arteries or ST-segment resolution after these therapies. Multiple strategies have been examined to treat these patients with "failed thrombolysis." We examined the existing medical literature regarding treatment of failed thrombolysis including strategies testing repeat thrombolytic therapy and rescue percutaneous coronary intervention. Additional, we reviewed the literature regarding the efficacy of transferring patient for rescue percutaneous intervention and coronary stenting. The impact of contemporary antiplatelet strategies, cardiogenic shock, and coronary bypass surgery was examined. Overall, the management of patients with acute STEMI in whom thrombolytic therapy failed remains a challenging problem. As a result, many different strategies are currently in use. Among these therapeutic interventions, rescue PCI with coronary stenting appears to be superior when it is done in a timely manner by an experienced center.