Establishing Consensus for Mohs Micrographic Surgical Techniques in the Treatment of Melanoma in Situ for Future Clinical Trials: A Modified Delphi Study.

BACKGROUND: Mohs micrographic surgery (MMS) is a promising treatment modality for melanoma in situ (MIS). However, variations in surgical technique limit the generalizability of existing data and may impede future study of MMS in clinical trials. METHODS: A modified Delphi method was selected to establish consensus on optimal MMS techniques for treating MIS in future clinical trials. The Delphi method was selected due to the limited current data, the wide range of techniques used in the field, and the intention to establish a standardized technique for future clinical trials. A literature review and interviews with experienced MMS surgeons were performed to identify dimensions of the MMS technique for MIS that (1) likely impacted costs or outcomes of the procedure, and (2) showed significant variability between surgeons. A total of 8 dimensions of technical variation were selected. The Delphi process consisted of 2 rounds of voting and commentary, during which 44 expert Mohs surgeons across the United States rated their agreement with specific recommendations using a Likert scale. RESULTS: Five of eight recommendations achieved consensus in Round 1. All 3 of the remaining recommendations achieved consensus in Round 2. Techniques achieving consensus in Round 1 included the use of a starting peripheral margin of ≤5 mm, application of immunohistochemistry, frozen tissue processing, and resecting to the depth of subcutaneous fat. Consensus on the use of Wood's lamp, dermatoscope, and negative tissue controls was established in Round 2. CONCLUSIONS: This study generated 8 consensus recommendations intended to offer guidance for Mohs surgeons treating MIS. The adoption of these recommendations will promote standardization to facilitate comparisons of aggregate data in multicenter clinical trials.

Identifying critical quality metrics in Mohs Surgery: A national expert consensus process.

BACKGROUND: Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. OBJECTIVE: The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. METHODS: Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. RESULTS: Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. LIMITATIONS: Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes. CONCLUSION: With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.

Quality and Readability of Online Educational Mohs Micrographic Surgery Resources.

BACKGROUND: As internet access continues to expand, online health care information is increasingly influencing patient decisions. Mohs micrographic surgery (MMS) is commonly used in the field of dermatology but may be unfamiliar to many patients. OBJECTIVE: The purpose of this study was to identify and analyze online educational resources regarding MMS and learn how to optimize the understanding and informational content of MMS for patients and their families. MATERIALS AND METHODS: Thirty-two websites were evaluated for authorship, quality, and readability using DISCERN, JAMA Benchmark Criteria, and Flesch-Kincaid tests. RESULTS: Physician-authored content showed a trend toward higher quality (p = .058). Google scored higher in specific DISCERN questions when overlapping websites were excluded. Bing scored higher in JAMA criteria (p = .03) in criteria such as authorship and currency. Higher DISCERN scores correlated with lower readability. CONCLUSION: Physician involvement improves content quality, raising questions about physicians' responsibility in online resource creation. Correlations between content quality and readability highlight potential challenges for certain demographics. Balancing medical accuracy with comprehensibility is crucial for equitable patient education. This study underscores the need to refine online resources, ensuring accurate, transparent, and accessible health care information.

Informed or misinformed consent and use of modified texture diets in dysphagia.

BACKGROUND: Use of modified texture diets-thickening of liquids and modifying the texture of foods-in the hope of preventing aspiration, pneumonia and choking, has become central to the current management of dysphagia. The effectiveness of this intervention has been questioned. We examine requirements for a valid informed consent process for this approach and whether the need for informed consent for this treatment is always understood or applied by practitioners. MAIN TEXT: Valid informed consent requires provision of accurate and balanced information, and that agreement is given freely by someone who knows they have a choice. Current evidence, including surveys of practitioners and patients in different settings, suggests that practice in this area is often inadequate. This may be due to patients' communication difficulties but also poor communication-and no real attempt to obtain consent-by practitioners before people are 'put on' modified texture diets. Even where discussion occurs, recommendations may be influenced by professional misconceptions about the efficacy of this treatment, which in turn may poison the well for the informed consent process. Patients cannot make appropriate decisions for themselves if the information provided is flawed and unbalanced. The voluntariness of patients' decisions is also questionable if they are told 'you must', when 'you might consider' is more appropriate. Where the decision-making capacity of patients is in question, inappropriate judgements and recommendations may be made by substitute decision makers and courts unless based on accurate information. CONCLUSION: Research is required to examine the informed consent processes in different settings, but there is ample reason to suggest that current practice in this area is suboptimal. Staff need to reflect on their current practice regarding use of modified texture diets with an awareness of the current evidence and through the 'lens' of informed consent. Education is required for staff to clarify the importance of, and requirements for, valid informed consent and for decision making that reflects people's preferences and values.

A post-mortem analysis of tenofovir, lamivudine, efavirenz and fluconazole penetration in female genital tissues.

BACKGROUND: Optimal penetration of anti-infectives in the female genital tract (FGT) is paramount in the treatment and prevention of infectious diseases. While exposure of anti-infectives in lower FGT tissues (e.g. cervix, vagina) has been described, little data exist on upper genital tissues (e.g. ovary, uterus). METHODS: Autopsies were performed and post-mortem tissues were collected within 24 h of death for female participants with advanced HIV in Uganda (n = 27). Tenofovir, lamivudine, efavirenz and fluconazole concentrations were measured using LC-MS/MS in plasma, ovarian, uterine, cervical and vaginal tissues. Tissue penetration was calculated as tissue-to-plasma concentration ratios (TPRs). RESULTS: TPRs of tenofovir, lamivudine and fluconazole were highest in vaginal tissue (medians 1.86, 1.83 and 0.94, respectively), while the TPR of efavirenz was highest in ovarian tissue (median 0.65). With cervix as a reference compartment, vaginal TPRs were significantly higher than cervical for all four drugs; TPRs of efavirenz in uterine and ovarian compartments were also significantly higher than cervical. Most of the post-mortem FGT samples had a TPR of greater than 1 for tenofovir and lamivudine, while less than 50% had a TPR of greater than 1 for both efavirenz and fluconazole. CONCLUSIONS: Penetration of anti-infectives was not homogeneous among the FGT compartments. Approximately 70% of FGT tissues had a TPR of greater than 1 for tenofovir and lamivudine, favouring the prevention of local HIV replication and transmission in the FGT.

Common Dermatologic Procedures and the Associated Complications Unique to Skin of Color.

BACKGROUND: The skin of color (SOC) population in the United States continues to grow, and these patients are undergoing various cosmetic and surgical procedures at increasing rates. There is a paucity of data on the potential complications associated with surgical and cosmetic procedures in this patient population. OBJECTIVE: We aim to educate dermatologic surgeons and clinicians on surgical and cosmetic procedures in patients of color and increase awareness of the potential complications unique to this patient population. MATERIALS AND METHODS: A thorough PubMed literature search was performed to conduct this review. RESULTS: There are a number of complications in SOC that require special attention, including keloids, postoperative infections, postinflammatory hyperpigmentation, and hypopigmentation. There are also various precautions to consider when performing cosmetic procedures, such as neurotoxin and filler injections, laser therapy, microneedling, and chemical peels. CONCLUSION: Dermatologists should be aware of the potential cosmetic and surgical complications of this growing patient population to provide optimal evidence-based medical care.

An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures.

BACKGROUND: Opioid overprescribing is a major contributor to the opioid crisis. The lack of procedure-specific guidelines contributes to the vast differences in prescribing practices. OBJECTIVE: To create opioid-prescribing consensus guidelines for common dermatologic procedures. METHODS: We used a 4-step modified Delphi method to conduct a systematic discussion among a panel of dermatologists in the fields of general dermatology, dermatologic surgery, and cosmetics/phlebology to develop opioid prescribing guidelines for some of the most common dermatologic procedural scenarios. Guidelines were developed for opioid-naive patients undergoing routine procedures. Opioid tablets were defined as oxycodone 5-mg oral equivalents. RESULTS: Postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. Group consensus identified no specific dermatologic scenario that routinely requires more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Group consensus found that 23% of the procedural scenarios routinely require 1 to 10 opioid tablets, and only 1 routinely requires 1 to 15 opioid tablets. LIMITATIONS: These recommendations are based on expert consensus in lieu of quality evidence-based outcomes research. These recommendations must be individualized to accommodate patients' comorbidities. CONCLUSIONS: Procedure-specific opioid prescribing guidelines may serve as a foundation to produce effective and responsible postoperative pain management strategies after dermatologic interventions.

Incidence of Epinephrine Reactions With Local Anesthesia in Mohs Micrographic Surgery.

BACKGROUND: The incidence of reactions to epinephrine-containing local anesthetics in Mohs micrographic surgery (MMS) has not been established. OBJECTIVE: To estimate the incidence of epinephrine-induced reactions from local anesthetics in patients who undergo MMS for the removal of cutaneous malignancies. METHODS: From 2016 to 2018, 200 MMS patients were recruited from the authors' surgical center. Assessments were obtained throughout the entirety of the Mohs cases during a single visit. RESULTS: This study estimated the incidence of epinephrine reactions in patients who undergo MMS to be 2.0% (95% confidence interval: 0.1%-3.9%). No relationship between epinephrine dose and incidence of adverse effects was found. Patient age was a significant risk factor for the development of an epinephrine reaction. CONCLUSION: Systemic reactions to epinephrine from local anesthetics are an infrequent adverse event in MMS cases. The data suggest that the absolute dose of local anesthetic with epinephrine does not correlate with the risk of developing an epinephrine reaction. Older age seems to have a protective effect.

Expert Opinion Regarding Appropriately Timing Dermatological Surgeries in Patients With Recent Myocardial Infarctions.

BACKGROUND: There is limited data on the risk of perioperative myocardial infarctions (MIs) in patients with a recent MI who undergo dermatologic surgeries. OBJECTIVE: Present the recommendations of dermatologic surgeons and cardiologists to determine the safety of dermatologic surgeries after a recent MI. METHODS: An electronic survey was distributed to Mohs surgeons and cardiologists to infer the risk of major adverse cardiac events (MACE) inherent to dermatologic surgery and determine timing of dermatologic surgery in patients with a recent MI. RESULTS: One hundred twenty Mohs surgeons and 30 cardiologists were surveyed. Ninety-seven percent of cardiologists and 87% of Mohs surgeons deemed cutaneous excisions and Mohs micrographic surgery as low-risk procedures with less than one-percent chance of MACE. Seventy-seven percent of cardiologists and 46% of Mohs surgeons stated dermatologic surgery should either not be delayed or be delayed up to 1 month after an MI. Responses between cardiologists and Mohs surgeons did not significantly differ. CONCLUSION: A preponderance of surveyed experts believe that most dermatologic surgeries may be safely performed in patients with a history of an MI within 1 month. The decision to implement urgent dermatologic surgery in patients with a recent MI should account for all clinically significant factors.

Pulsed dye laser repurposed: Treatment of refractory molluscum contagiosum in renal transplant patient.

We present a case of a 15-year-old girl with an allogenic renal transplant secondary to chronic glomerulonephritis of unknown etiology who presented with treatment refractory molluscum contagiosum of the lower extremities and perineum. Treatment of mollusca with pulsed dye laser resulted in a clinically significant and sustained response. To our knowledge, this is the first report of a successful treatment of molluscum contagiosum with pulsed dye laser in the setting of a renal transplant.

Public Recognition and Perceptions of Obsessive Compulsive Disorder.

Previous research has indicated that the public's knowledge on obsessive compulsive disorder (OCD) is poor. Public understanding and perception of OCD may be one contributor to this issue. Given that mental health literacy is an important first step for those to receive the appropriate care, we sought to understand more about the public's awareness and perceptions of OCD. Data regarding knowledge of OCD were collected through a New York statewide telephone survey (N = 806). Results indicated that those who had never heard of OCD were more likely to be ethnic minorities, have a lower income, and less education. Most participants described OCD either in terms of compulsions or in terms of perfectionism. Almost half (46.5%) of participants did not think there is a difference between someone with OCD and someone who is obsessive-compulsive. These findings are consistent with previous literature regarding race and treatment seeking behaviors.

A Preliminary Investigation of Pathways to Inflated Responsibility Beliefs in Children with Obsessive Compulsive Disorder.

BACKGROUND: Cognitive theorists posit that inflated responsibility beliefs contribute to the development of obsessive compulsive disorder (OCD). Salkovskis et al. (1999) proposed that experiencing heightened responsibility, overprotective parents and rigid rules, and thinking one influenced or caused a negative life event act as 'pathways' to the development of inflated responsibility beliefs, thereby increasing risk for OCD. Studies in adults with OCD and non-clinical adolescents support the link between these experiences and responsibility beliefs (Coles et al., 2015; Halvaiepour and Nosratabadi, 2015), but the theory has never been tested in youth with current OCD. AIMS: We provided an initial test of the theory by Salkovskis et al. (1999) in youth with OCD. We predicted that childhood experiences proposed by Salkovskis et al. (1999) would correlate positively with responsibility and harm beliefs and OCD symptom severity. METHOD: Twenty youth with OCD (age 9‒16 years) completed a new child-report measure of the experiences hypothesized by Salkovskis et al. (1999), the Pathways to Inflated Responsibility Beliefs Scale-Child Version (PIRBS-CV). Youth also completed the Obsessive Beliefs Questionnaire-Child Version (Coles et al., 2010) and the Obsessive Compulsive Inventory-Child Version (Foa et al., 2010). RESULTS: Consistent with hypotheses, the PIRBS-CV was significantly related to responsibility and harm beliefs and OCD symptom severity. CONCLUSIONS: Results provide initial support for the theory proposed by Salkovskis et al. (1999) as applied to youth with OCD. Future studies are needed to further assess the model in early-onset OCD.

Applying a Visual Assessment Tool to Facial Linear Scars.

Previous scar scales have focused on verbal descriptions. A nonverbal visual assessment tool would provide a simple way for patients and physicians to quantify scar appearance. The authors sought to use a validated visual assessment tool for linear surgical scars to assess linear scars on the face and to determine whether patients and surgeons rate scars similarly. A total of 143 patients with linear facial scars resulting from repair of Mohs micrographic surgery defects used the visual assessment tool to rate their surgical scar. Six physicians used the tool to rate a subset of the patients' scar photographs. The scar ratings for patients and physicians were compared. Among the scars rated by both the patients and physicians (n = 79), patients had a significantly lower mean (i.e., more favorable) rating compared with the physicians. This was a single-center study including only Caucasian patients. The visual assessment tool to rate linear surgical scars provided a simple method for both patients and physicians to assess the overall appearance of postsurgical scars. Difference in the scar ranking between patients and physicians indicate the importance of incorporating both patient and physician point of view when assessing scars.

Squamous Cell Carcinoma Arising in Hypertrophic Lichen Planus: A Review and Analysis of 38 Cases.

BACKGROUND: Hypertrophic lichen planus is a chronic variant of lichen planus with controversial malignant association. OBJECTIVE: To describe and analyze the relationship of squamous cell carcinoma (SCC) and hypertrophic lichen planus. MATERIALS AND METHODS: A retrospective chart review of patients with hypertrophic lichen planus and SCC was performed at the authors' institution. Thereafter, scientific databases were searched for articles reporting cases of SCC arising in hypertrophic lichen planus. Patient demographics, immune status, lichen planus features, and SCC data points were extracted for each patient and evaluated. RESULTS: Thirty-eight cases of SCC in hypertrophic lichen planus occurred in 16 women, average age: 61.4, and 22 men, average age: 51.3, after a lag time of 88 days to 40 years. Squamous cell carcinoma was uniformly located on the lower extremity. Men had larger SCC than women (p = .027) and a significantly longer lag time to SCC development (p = .002). Long lag time was associated with a smaller SCC size (p = .032). CONCLUSION: In the past, hypertrophic lichen planus and SCC have been considered isolated diseases. Based on an increasing number of cases, the association between hypertrophic lichen planus and keratinocyte malignancies warrants surveillance.

Alterations and Preservations: Practices and Perspectives of Speech-Language Pathologists Regarding the Intervention of Thickened Liquids for Swallowing Problems.

PURPOSE: The intervention of thickened liquids (TL) is commonly used to reduce aspiration in people with dysphagia. Speech-language pathologists (SLPs) have traditionally believed it is an effective intervention. Recent articles highlight limited evidence, poor acceptance, and a variety of unintended consequences. This study explores if current debates have been reflected in SLP practices and perspectives. METHOD: An e-survey was developed. Participants were recruited via professional associations in Australia, New Zealand, Ireland, the United Kingdom, and the United States. Descriptive and inferential statistics were used to explore the data. Principal component analysis was used to summarize SLP practices and perspectives. RESULTS: The 370 respondents represented mainly experienced, confident, hospital-based clinicians. While 20% of respondents frequently recommend TL, 61% believe it to be a burdensome treatment. "Best treatment" and "It works" beliefs continue to underpin decision making. Those who recommend TL most often are most influenced by penetration, coughing, and their own clinical experience. They are more likely to believe TL is evidence based and effective, reduces aspiration, and improves hydration. Person-centeredness is important among all respondents, although significant numbers would implement TL against patient wishes. Improvements in aspiration status and quality of life rank highly as reasons to discontinue TL. CONCLUSIONS: The results of this study suggest that fewer respondents are regularly using TL. Divergent groups are evident with those frequently employing and believing in the efficacy of TL and those who do not. While current debates are influencing practice, there clearly remains a significant number of SLPs continuing to recommend TL. This study's findings highlight both alterations and preservations in the discipline's approach to TL and calls for SLPs to reframe our thinking regarding this intervention as well as consider alternative options in this treatment space. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24317110.