Narcotic Use for Acute Postoperative Pain Management in Mohs Micrographic Surgery Patients With End Stage Renal Disease: A Review of the Literature.

BACKGROUND: Uncontrolled acute postoperative pain presents a significant management challenge when opioids are used in patients with end-stage renal disease (ESRD). Currently, there is a lack of quality pharmacokinetic and pharmacodynamic data regarding opioid medication use in ESRD patients to optimize safe and effective management. OBJECTIVE: To review the published literature on pharmacologic evidence for and against the use of opioid medications for acute postoperative pain following Mohs micrographic surgery in ESRD patients. METHODS: A search of PubMed was conducted to identify articles on the pharmacokinetic and pharmacodynamic properties of opioid pain medications in ESRD patients through March 1, 2020. RESULTS: Seventy-five articles were reviewed. Limited data exist on opioids safe for use in ESRD and are mostly confined to small case series. Studies suggest tramadol and hydromorphone could be considered when indicated. Methadone may be a safe option, but should be reserved for treatment coordinated by a trained pain subspecialist. CONCLUSION: Randomized clinical trials are lacking. Studies that are available are not sufficient to perform a quantitative methodologic approach. Evidence supports the judicious use of postoperative opioid medications in ESRD patients at the lowest possible dose to achieve clinically meaningful improvement in pain and function.

Cutaneous angiosarcoma of the lower leg.

Angiosarcoma is a vascular malignancy that can affect various anatomic sites. Although rare, cutaneous angiosarcoma is the most common clinical manifestation, accounting for approximately 50% to 60% of cases. Cutaneous angiosarcoma typically is known to occur in 3 settings: (1) idiopathic, (2) following radiation treatment, and (3) in the setting of chronic lymphedema following mastectomy (known as Stewart-Treves syndrome). The clinical manifestation of angiosarcoma can mimic other processes. We present a case of cutaneous angiosarcoma on the leg in an elderly woman in the setting of a chronic nonhealing wound and lymphedema. We also discuss the differential diagnosis and treatment options.

14-3-3 in Thoracic Aortic Aneurysms: Identification of a Novel Autoantigen in Large Vessel Vasculitis.

OBJECTIVE: Large vessel vasculitides (LVV) are a group of autoimmune diseases characterized by injury to and anatomic modifications of large vessels, including the aorta and its branch vessels. Disease etiology is unknown. This study was undertaken to identify antigen targets within affected vessel walls in aortic root, ascending aorta, and aortic arch surgical specimens from patients with LVV, including giant cell arteritis, Takayasu arteritis, and isolated focal aortitis. METHODS: Thoracic aortic aneurysm specimens and autologous blood were acquired from consenting patients who underwent aorta reconstruction procedures. Aorta proteins were extracted from both patients with LVV and age-, race-, and sex-matched disease controls with noninflammatory aneurysms. A total of 108 serum samples from patients with LVV, matched controls, and controls with antinuclear antibodies, different forms of vasculitis, or sepsis were tested. RESULTS: Evaluation of 108 serum samples and 22 aortic tissue specimens showed that 78% of patients with LVV produced antibodies to 14-3-3 proteins in the aortic wall (93.7% specificity), whereas controls were less likely to do so (6.7% produced antibodies). LVV patient sera contained autoantibody sufficient to immunoprecipitate 14-3-3 protein(s) from aortic lysates. Three of 7 isoforms of 14-3-3 were found to be up-regulated in aorta specimens from patients with LVV, and 2 isoforms (ε and ζ) were found to be antigenic in LVV. CONCLUSION: This is the first study to use sterile, snap-frozen thoracic aorta biopsy specimens to identify autoantigens in LVV. Our findings indicate that 78% of patients with LVV have antibody reactivity to 14-3-3 protein(s). The precise role of these antibodies and 14-3-3 proteins in LVV pathogenesis deserves further study.