A Pearl for Pretibial and Forearm Repair Following Mohs Micrographic Surgery.

Wound repair of the pretibial and forearm regions presents a challenge during dermatologic surgery as these areas are under significant tension and exhibit increased skin fragility. Various methodologies have been proposed for the closure and repair of such wounds, however, the use of the bilayered suture technique may be simpler and more effective than other techniques such as the pinch stitch, pully stitch, slip-knot stitch, pulley set-back dermal suture, horizontal mattress suture, pully stitch, and tandem pulley stitch. Our objective was to describe a novel method for the repair of pretibial and forearm wounds following Mohs micrographic surgery utilizing bilayered closure followed by tissue adhesive application.  J Drugs Dermatol. 2024;23(5):380.     doi:10.36849/JDD.7139  .

Impact of the COVID-19 Pandemic on Surgical Education and Training: A Resident Survey in a Developing Country.

Background The COVID-19 pandemic has adversely affected medical education and training programs worldwide. Early investigations have shown that surgical residents face a lot of challenges in these unprecedented times. This study aims to assess the impact of the COVID-19 pandemic on surgical education and training in a developing country. Methods This cross-sectional study was conducted in Allied Hospitals of Rawalpindi Medical University, Rawalpindi, Pakistan from June 2021 to July 2021. A structured questionnaire designed by the researchers was distributed to all surgery departments, and surgical residents who consented to participate in this study were included. Results A total of 152 residents participated in this study, of which 53 (34.9%) were in general surgery and 99 (65.1%) in various surgical allied specialties. Of the residents, 14.5% reported full transfer from the parent unit to the COVID-19 unit. An increase in emergency surgical procedures was reported by 52.8% of general surgery residents as compared to surgical allied specialties (P = 0.037). Of the residents, 90.1% reported increased stress and anxiety levels, with the number of allied residents significantly higher than general surgery residents (P = 0.031). A total of 125 (82.2%) respondents claimed that fear of contracting the virus affected proper patient evaluation. Conclusion The COVID-19 pandemic has severely impacted the training and psychological well-being of surgical residents.

Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study.

Importance: It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. Objective: To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. Design, Setting, and Participants: This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. Exposures: Mohs surgery for nonmelanoma skin cancer. Main Outcomes and Measures: Reason for treatment selection. Results: Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance: This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Tracheostomy dislodgement: Are obese patients at increased risk?

BACKGROUND: Obesity is a risk factor for tracheostomy-related complications. We aimed to investigate whether obesity was associated with a risk of unplanned tracheostomy dislodgement or decannulation (DD). METHODS: Retrospective review of patients undergoing tracheostomy at a single institution from 2013 to 2019 was performed. The primary outcome was unplanned DD within 42 days. Obesity was assessed by body mass index (BMI) and skin-to-trachea distance (STT) measured on computed tomographic images. RESULTS: 25 (12%) episodes of unplanned DD occurred in 213 patients within 42 days. BMI ≥35 kg/m2 was associated with STT ≥80 mm (p < 0.0001). On multivariate analysis, STT ≥80 mm but not BMI was an independent predictor of unplanned DD (hazard ratio = 8.34 [95% confidence interval 2.85-24.4]). CONCLUSIONS: STT ≥80 mm was a better predictor of unplanned DD than BMI. Assessment of STT in addition to BMI may be useful to identify patients that would benefit from extended length tracheostomy tubes.

Comparison of Open Appendectomy and Laparoscopic Appendectomy in Perforated Appendicitis.

Introduction Laparoscopic appendectomy for nonperforated appendicitis is associated with improved outcomes. This study compares laparoscopic appendectomy and open appendectomy in cases of a perforated appendix by assessing surgical site infection, mean operating time, and length of hospital stay. Materials and methods This study was a prospective randomized study conducted at the Department of Surgery, Holy Family Hospital, Rawalpindi, Pakistan, from January 2016 to January 2017, by randomly allotting the laparoscopic or the open appendectomy technique to 130 patients by the lottery method. Patients having a perforated appendix were included after they provided informed consent. Data were entered and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, US). Results The frequency of wound site infection was significantly higher in open appendectomy (27.69%) than in the laparoscopic approach (10.77%; p=0.01). Mean hospital stay was slightly longer in the laparoscopic approach (4.38 ± 1.09 days) than in open appendectomy (4.18 ± 0.77 days; p=0.23). Mean operating time for laparoscopic appendectomy and open appendectomy was 46.98 ± 2.99 minutes and 53.02 ± 2.88 minutes, respectively (p<0.000). Conclusion Laparoscopic appendectomy was associated with fewer surgical site infections and shorter mean operating time than an open appendectomy.

A Spectrum of Hematological Disorders in Children with Pancytopenia Based on Bone Marrow Examination in a Tertiary Care Hospital.

Introduction Pancytopenia is a common presentation in the pediatric population. It is a manifestation of various diseases, and its etiology can be explained on the basis of bone marrow examination. The study aims to determine the etiological factors leading to pancytopenia via bone marrow examination in pediatric patients presenting in our hospital. Materials and methods This retrospective cross-sectional study was conducted in the Department of Pathology at a public sector tertiary care hospital. Data were recorded by convenience sampling from the patients' database from January 2015 to April 2018. Patients aged 2 months to 15 years who had pancytopenia on peripheral blood smear and were admitted for bone marrow examination were included in the study. Patients who were beyond these age limits, diagnosed cases of aplastic anemia and leukemia, and those with a recent history of blood transfusion were excluded from the study. The analysis was done via the Statistical Package for Social Sciences (SPSS) v.23.0 (IBM SPSS Statistics, Armonk, NY, USA), and descriptive statistics were applied. Results Of 115 cases, 58 (50.4%) were males and 57 (49.6%) were females. Megaloblastic anemia was present in 32 (27.8%) patients, and it was the most common cause of pancytopenia. Non-malignant disorders were seen in 95 cases (82.6%) and malignant disorders were seen in 20 (17.4%) cases. Conclusion Megaloblastic anemia is the most common cause, and acute lymphoblastic leukemia is the most common malignant cause of pancytopenia in children. There was no significant gender predilection among causes of pancytopenia.

Role of Preoperative Administration of Vitamin D and Calcium in Postoperative Transient Hypocalcemia after Total Thyroidectomy.

Introduction Thyroid surgery is one of the most frequently performed surgical procedures worldwide. Total thyroidectomy is a recommended procedure for most of the thyroid diseases. The most common complication resulting after this surgery is transient hypocalcemia - the incidence is 24% - which increases the morbidity rate and increases the length of stay in the hospital. The objective of our study was to compare the frequency of transient hypocalcemia after vitamin D and calcium supplementation with the control group for patients undergoing total thyroidectomy. Patients and methods It was a randomized controlled trial conducted at Department of Surgery, Pakistan Atomic Energy Commission General Hospital, Islamabad, Pakistan from January 2017 to July 2017. A total of 92 patients of both genders undergoing total thyroidectomy were included in the study. Patients undergoing reoperation for thyroid disease, American Society of Anesthesiologists (ASA) grade 3 or above, patients with chronic renal failure, preoperative hypocalcemia or hypercalcemia were excluded. The patients were sorted into two groups by lottery method; Group 1 in which Vitamin D (2,00,000 IU) and calcium (1 gm) was given 24 hours preoperatively. Group 2 was the control group. Total thyroidectomy was done and serum calcium levels were evaluated immediately after surgery on day two, seven and on the 30th day. The final outcome was measured at one month. Data was analyzed via the Statistical Package for Social Sciences version 22.0 (IBM Corp, Armonk, NY, USA). P value ≤ 0.05 was considered significant. Results The age ranged from 18 to 65 years with the mean age of 38.673 ± 8.63 years in group 1 while 41.217 ± 9.52 years in group 2, mean preoperative calcium level was 9.482 ± 0.49 mg/dl in group 1 and 9.678 ± 0.54 mg/dl in group 2. Hypocalcemia was seen in 3 (6.5%) in group 1 as compared to 12 (26.1%) patients in group 2 (p = 0.011). Conclusion Preoperative oral calcium and vitamin D supplements may prevent postoperative hypocalcemia, allowing a safe and early discharge. This will ultimately lead to improved patient satisfaction and significant cost savings.

"Deep" vertical Mohs and closure with a tumor-free flap for dermatofibrosarcoma protuberans: A case report.

Dermatofibrosarcoma protuberans is an uncommon low-grade malignant tumor that can invade locally and rarely metastasize. Dermatofibrosarcoma protuberans has a high rate of local recurrence due to incomplete excision, especially in deep tissues. Morbidity is often related to multiple local recurrences and removal of excessive tissue with large, complex repairs. We present a case of incompletely excised dermatofibrosarcoma protuberans after initial wide local excision. We subsequently employed a "deep" vertical Mohs micrographic surgical technique to remove the remaining tumor while creating a flap with the tumor-free superficial portion to preserve tissue and avoid a complicated repair. The patient is tumor-free for 7 years.

Life of a Wound: Serial Documentation of Wound Healing After Shave Removal Using Reflectance Confocal Microscopy

Reflectance Confocal Microscopy (RCM) is a new noninvasive skin imaging modality that is comparable to traditional histopathology. We present serial in vivo RCM imaging of an atypical nevus after shave excision over a 1-month period. Findings on RCM images are consistent with the inflammatory, proliferative, and remodeling phases of wound healing, and RCM may serve as a new tool to study wound healing in vivo over time. J Drugs Dermatol. 2019;18(5):472-474.