Nevus sebaceus with syringocystadenoma papilliferum, prurigo nodularis, apocrine cystadenoma, basaloid follicular proliferation, and sebaceoma: case report and review of nevus sebaceus-associated conditions.

Nevus sebaceus is a benign skin hamartoma of congenital onset that grows during puberty, and in adulthood can develop secondary benign and malignant neoplasms. The most common benign neoplasms occurring in nevus sebaceus are believed to be syringocystadenoma papilliferum, trichilemmoma, and trichoblastoma. A patient with nevus sebaceus developed not only syringocystadenoma papilliferum but also prurigo nodularis within her hamartomatous lesion; multiple biopsies were necessary to establish the diagnoses. Excision of the residual nevus sebaceus also revealed an apocrine cystadenoma, basaloid follicular proliferation, and sebaceoma. Also, it is important to select the appropriate biopsy site and size when evaluating a patient for secondary neoplasms within their nevus sebaceous. Indeed, more than one biopsy may be required if additional diagnoses are suspected.

Optimal design for high-throughput screening via false discovery rate control.

High-throughput screening (HTS) is a large-scale hierarchical process in which a large number of chemicals are tested in multiple stages. Conventional statistical analyses of HTS studies often suffer from high testing error rates and soaring costs in large-scale settings. This article develops new methodologies for false discovery rate control and optimal design in HTS studies. We propose a two-stage procedure that determines the optimal numbers of replicates at different screening stages while simultaneously controlling the false discovery rate in the confirmatory stage subject to a constraint on the total budget. The merits of the proposed methods are illustrated using both simulated and real data. We show that, at the expense of a limited budget, the proposed screening procedure effectively controls the error rate and the design leads to improved detection power.

A 4-year retrospective assessment of postoperative complications in immunosuppressed patients following Mohs micrographic surgery.

BACKGROUND: Many patients undergoing Mohs micrographic surgery for basal and squamous cell carcinomas are immunocompromised, yet postoperative complications associated with different types of immunosuppression are largely unstudied. OBJECTIVE: To determine the incidence and nature of postoperative complications in immunosuppressed patients undergoing Mohs micrographic surgery. METHODS: A retrospective cross-sectional chart review of patient characteristics, clinical characteristics, and complications. RESULTS: Univariable analysis showed that compared with immunocompetence, immunosuppression was associated with 9.6 times the odds of postoperative complication (P = .003), with solid organ transplant recipients having 8.824 times higher odds (P = .006) and immunosuppressive therapy use displaying 5.775 times higher odds (P = .021). Surgical site infection (2.5%) and dehiscence (0.51%) were more prevalent among immunosuppressed patients, with an overall complication rate of 5.4% in the immunosuppressed population. Multivariable analysis of the association between immunosuppression and postoperative complication closely trended toward, but did not meet, significance (P = .056). LIMITATIONS: This was a single-center, retrospective study. Other limitations include lack of non-solid organ transplants, limited medication-related data on nontransplant patients, and exclusion of cases involving patients with double transplants or multiple sources of immunosuppression. CONCLUSIONS: Immunosuppression overall, particularly owing to solid organ transplant and immunosuppressive therapy use, places patients at higher risk for postoperative complications, including surgical site infection and wound dehiscence following MMS.

Critical Appraisal of the Impact of the Systematic Adoption of Advanced Minimally Invasive Hepatobiliary and Pancreatic Surgery on the Surgical Management of Mirizzi Syndrome.

BACKGROUND: Minimally invasive surgery (MIS) for Mirizzi syndrome (MS) remains a technically challenging procedure with a high open conversion rate. We critically evaluated the impact of the systematic adoption of MI-HBP surgery on the surgical outcomes of MS. METHODS: Ninety-five patients who underwent surgery for MS were retrospectively reviewed. Systematic adoption of advanced MI-HBP surgery started in 2012. The cohort was classified into a preadoption (2002-2012) (Era 1, n = 58) and post-adoption (2013-2017) (Era 2, n = 37). Furthermore, Era 2 was divided into a cohort operated by advanced minimally invasive surgeons (AMIS) (Era 2 AMIS, n = 19) and those by other surgeons (Era 2 others, n = 19). RESULTS: Comparison between Era 2 and Era 1 demonstrated a significant increase in the frequency of MIS attempted (89% vs 33%, p < 0.01), increase in the use of choledochoplasty (24% vs 2%, p < 0.01), increase operation time (180 min vs 150 min, p = 0.03) and significantly lower open conversion rate (24% vs 58%, p < 0.01). Comparison between Era 2 AMIS and Era 2 others demonstrated a significantly greater adoption of MIS (100% vs 78%, p = 0.046) with lower open conversion rate (5% vs 50%, p = 0.005). Comparison between all attempted MIS cases with open procedures demonstrated a significantly higher proportion of subtotal cholecystectomies performed (40% vs 23%, p = 0.04), choledochoplasty (17% vs 2%, p = 0.04) and shorter hospital stay (4 days vs 9 days, p < 0.01). CONCLUSIONS: Systematic adoption of advanced MI-HBP surgery allowed surgeons to perform MIS for MS more frequently and with a significantly lower open conversion rate. Patients who underwent successful MIS had the shortest hospital stay compared to patients who underwent open surgery or required open conversion.

Mode of presentation rather than the 'weekend effect' is a major determinant of in-hospital mortality.

BACKGROUND: The influence of patient demographics and mode of admission on the 'weekend effect' remains unclear. This study examins the relationship between day of admission, patient demographics, mode of presentation and survival. METHODS: Hospital admissions over a three-year period were studied. Patients with an inpatient stay less than 24 h and those who were discharged from the emergency department were excluded. In-hospital mortality was correlated with day of admission, age, gender and mode of presentation in a binary logistical regression analysis. RESULTS: There were 448,827 admissions, of which 350,648 (85.7%) occurred during a weekday. 256,777 (62.7%) were emergency presentations, which was closely related to a weekend admission (92.3% vs 57.8%, p < 0.001). There were 8099 deaths of which 6336 (78.2%) related to a weekday admission and 1736 (21.4%) related a weekend admission. Mortality for elective admissions was 78 (0.05%) compared to 8021 (3.12%), p < 0.001 in emergency admissions. Univariable regression analysis revealed a weekend admission (Odds Ratio (OR) 1.68 (95% confidence interval (CI) 1.60-1.78, p < 0.001) and emergency presentation (OR 63.02 (95%CI 50.42-78.77), p < 0.011) were associated with weekend mortality. On multivariable analysis the OR for weekend admission reduced to 1.07 (95%CI 1.01-1.13), p = 0.013 and the OR for emergency presentation increased to 76.68 (95%CI 61.40-96.00), p < 0.001. CONCLUSION: This study highlights that higher weekend mortality rates are a consequence of a lower proportion of elective admissions. Extending the working week to seven days might reduce weekend mortality without reducing the total number of deaths.

A Retrospective Assessment of Postoperative Bleeding Complications in Anticoagulated Patients Following Mohs Micrographic Surgery.

BACKGROUND: A significant number of patients undergoing Mohs micrographic surgery (MMS) for skin cancer are treated with oral anticoagulants. The incidence of postoperative complications associated with new classes of oral anticoagulants remains largely unknown. OBJECTIVE: To determine the incidence of postoperative complications in patients undergoing MMS on both traditional oral anticoagulants and new novel oral anticoagulants. MATERIALS AND METHODS: A single-center retrospective chart review was performed for all patients treated with oral anticoagulants who underwent MMS between July 1, 2012 and June 30, 2015 at University of California, San Diego. RESULTS: The data from this study demonstrated that patients treated with a novel oral anticoagulant at the time of MMS had a statistically significant greater risk for developing postoperative hemorrhagic complications compared to patients treated with traditional oral anticoagulants. CONCLUSION: Dermatologic surgeons should manage both traditional oral anticoagulants and novel oral anticoagulants in a similar manner. Future studies are warranted.

A Retrospective Analysis of Complication Rates in Mohs Micrographic Surgery Patients With Clinically Large Tumors and Tumors With Aggressive Subclinical Extension.

BACKGROUND: Clinically large cutaneous tumors and those with aggressive subclinical extension (ASE) often require wider margins and increased operative time during Mohs micrographic surgery (MMS). Our goal is to improve dermatologic surgeons' counseling information on complication risks for aggressive tumors. OBJECTIVE: To examine the incidence of postoperative complications in MMS patients, with a focus on differences between aggressive and non-aggressive tumors. METHODS AND MATERIALS: We performed a retrospective cross-sectional chart review of 4151 MMS cases at the University of California, San Diego. A postoperative complication was defined as an adverse event directly related to MMS reported within 6 weeks of the procedure. RESULTS: Clinically, large tumors had 50 times the odds of postoperative complication as compared to all other tumors (P less than 0.001). ASE was not found to be significantly associated with higher rates of postoperative complications when controlled for other factors. CONCLUSION: Clinically, large tumors may be at higher risk for complications following MMS due to their increased size and need for repair with methods other than linear closures. Tumors with ASE were not found to be at higher risk for postoperative complications. J Drugs Dermatol. 2018;17(5):511-515.

Confluent and Reticulated Papillomatosis Associated with Polycystic Ovarian Syndrome.

Polycystic ovarian syndrome is an endocrine disorder diagnosed commonly in young women. Various cutaneous manifestations can include acanthosis nigricans, acne, hirsutism, and alopecia. Confluent and reticulated papillomatosis is a rare skin condition that may be associated with polycystic ovarian syndrome. The etiology of confluent and reticulated papillomatosis is not yet well established but multiple theories exist regarding its pathogenesis. We describe a woman with established polycystic ovarian syndrome who presented with confluent and reticulated papillomatosis; her skin condition was successfully treated with azithromycin. The clinical features, differential diagnosis, epidemiology, and proposed etiologies for confluent and reticulated papillomatosis are discussed as well as possible treatment options. Among women with polycystic ovarian syndrome, confluent and reticulated papillomatosis and acanthosis nigricans can occur concurrently. Additionally, it is possible that confluent and reticulated papillomatosis occurs more commonly in this patient population.

Alcohol-Associated Immunoglobulin A Vasculitis: A Case Report and Review of the Literature.

Immunoglobulin A (IgA)-mediated leukocytoclastic vasculitis is a cutaneous small-vessel vasculitis characterized by skin findings of palpable purpura. It may occur secondary to infections, neoplasms, drugs, and systemic conditions, although it is most commonly idiopathic. A known, but rare, trigger for IgA vasculitis is alcohol consumption. We present a case of a man with IgA vasculitis associated with alcohol use and review the literature on alcohol-associated vasculitis. Although rarely reported, alcohol-associated IgA vasculitis is an important entity to consider for appropriate diagnosis and management of such patients.

Osteoma Cutis: An Adverse Event Following Tattoo Placement.

Osteoma cutis can occur as a primary or secondary cutaneous lesion. Isolated lesions of perforating osteoma cutis are uncommon and can present with varying clinical features. Adverse events that can occur following placement of a tattoo include benign and malignant neoplasms, dermatoses, infections, and miscellaneous complications. We present a case of a man who developed perforating osteoma cutis within a tattoo and propose that osteoma cutis be included among the list of adverse events that can occur in individuals who obtain a tattoo.

Macrolunula: Case Reports of Patients with Trauma-associated Enlarged Lunula and a Concise Review of this Nail Finding.

The lunula refers to the visible portion of the distal nail matrix that extends beyond the proximal nail fold. Macrolunula, or enlarged lunula, is not only a physiologic variant but also has been associated with a variety of local and systemic disorders. Macrolunula has been described in congenital conditions including hereditary onycho-osteodysplasia, neoplasms such as superficial acral fibromyxoma, as well as iatrogenic causes as in the topical administration of hydrocortisone; it can also occur in systemic disorders including hyperthyroidism, ischemia, leprosy, and scleroderma. While macrolunula has been described in self-induced trauma secondary to habit-tic deformity, we observe in this case report that any mechanism of trauma to the nail unit may produce enlargement of the lunula.

Penile Angiokeratoma (Peaker): A Distinctive Subtype of Genital Angiokeratoma.

Penile angiokeratomas (peakers) are uncommon, benign vascular tumors typically presenting as multiple lesions on the corona of the glans penis. They have been observed in 21 men. They range from 0.5 to 5 millimeters in size and initially appear in both young and old men. They are usually asymptomatic and are managed conservatively. They are rarely associated with systemic diseases. Symptomatic or cosmetically undesirable lesions can be treated with cryotherapy, electrodessication, excision, laser therapy, or sclerotherapy. We present a man with a solitary angiokeratoma of the glans penis and discuss the unique features of penile angiokeratomas.

Weighted False Discovery Rate Control in Large-Scale Multiple Testing.

The use of weights provides an effective strategy to incorporate prior domain knowledge in large-scale inference. This paper studies weighted multiple testing in a decision-theoretic framework. We develop oracle and data-driven procedures that aim to maximize the expected number of true positives subject to a constraint on the weighted false discovery rate. The asymptotic validity and optimality of the proposed methods are established. The results demonstrate that incorporating informative domain knowledge enhances the interpretability of results and precision of inference. Simulation studies show that the proposed method controls the error rate at the nominal level, and the gain in power over existing methods is substantial in many settings. An application to a genome-wide association study is discussed.

National Survey of Neurosurgeons and Stroke Physicians on Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction.

BACKGROUND: Several studies have evaluated the use of decompressive hemicraniectomy (DHC) in malignant middle cerebral artery infarction (MMCAI). In the United Kingdom, the National Institute for Health and Care Excellence (NICE) has set criteria for selection of patients for DHC in MMCAI. We set out to survey the attitudes and practice of neurosurgeons and stroke physicians within the United Kingdom towards DHC in MMCAI. METHODS: An electronic survey of questions on management of MMCAI in various clinical scenarios was submitted to the academic committees of the Society of British Neurological Surgeons and the British Association of Stroke Physicians for approval before dissemination through the consultant members. Responses were collected over 2 months. RESULTS: A total of 78 responses, from 51 neurosurgeons and 27 stroke physicians, were included in final analysis. A total of 54% and 24% of all respondents would recommend DHC in patients aged 60-70 and 70-80 years, respectively; 60% would advocate surgery between 48 and 72 hours and 27% beyond 72 hours. A total of 36% indicated DHC with preoperative Glasgow Coma Scale 15/15. These findings do not conform to current NICE guidelines. Stroke physicians were statistically more likely to recommend DHC in patients older than 60 years (P = 0.032) and in those with dominant multiterritorial infarcts (P = 0.042) and accept a greater postoperative modified Rankin Scale (P = 0.034) compared with neurosurgeons. CONCLUSIONS: In view of evidence from recent trials and differences in NICE guidelines and current clinical practice within the United Kingdom, based on our survey results, it is important to reevaluate NICE guidelines.

A case of Finegoldia magna (formerly Peptostreptococcus magnus) infection mimicking disseminated malignancy.

A 44-year-old alcoholic (and therefore immunocompromised) hospital cleaner presented with general malaise, weight loss, and erythematous skin nodules. Computed tomography scanning revealed a neck mass invading the thyroid gland, pulmonary infiltrates, liver lesions, and deposits on the anterior abdominal wall, consistent with disseminated malignancy. However, tissue diagnosis showed a necro-inflammatory process with no evidence of malignancy. Microscopy and culture of samples failed to detect any infectious pathogen, but after an extended incubation period, Finegoldia magna was isolated. This case study illustrates the importance of tissue diagnosis in suspected disseminated malignancy and raises the risk of acquiring the rarer bacteria amongst hospital staff.