Cheek Donor Site for Full-Thickness Skin Graft Repair of the Nasal Ala: Outcomes of a Retrospective Cohort Study.

BACKGROUND: Full-thickness skin grafts (FTSGs) are useful repairs for reconstructing nasal alar defects. Traditional donor sites include the preauricular, postauricular, and supraclavicular skin. OBJECTIVE: To evaluate esthetic outcomes and complications of nasal alar defects repaired with FTSGs from the medial cheek. MATERIALS AND METHODS: A retrospective chart review of Mohs surgery patients who had FTSG repair of the nasal ala between January 2015 and August 2020 was performed. Demographic, surgery, and follow-up visit data were reviewed. Cosmesis was rated by a facial plastic surgeon, a Mohs surgeon, and a plastic surgeon using baseline, defect, and follow-up visit photographs. RESULTS: Sixty-nine patients with FTSG repairs of nasal alar defects were identified. 51 of 69 patients (73.9%) had the cheek donor site, and 18 of 69 patients (26.1%) had a noncheek donor site. The mean (SD) rater visual analog score for both cohorts was good with no significant difference (cheek: 65.9 [13.8]; noncheek: 66.1 [15.3]; p = .96). A notable difference in the complication rate by donor site was observed (cheek: 6.9%, noncheek: 16.7%; p = .13), although it did not reach significance. CONCLUSION: The cheek is a reliable FTSG donor site for nasal alar defects after Mohs micrographic surgery, with a trend toward fewer complications.

Umbilical Cord Milking in Extremely Preterm Infants: A Randomized Controlled Trial Comparing Cord Milking with Immediate Cord Clamping.

OBJECTIVE: This study aimed to assess potential benefits of umbilical cord milking (UCM) when compared with immediate cord clamping (ICC) in extremely preterm infants. STUDY DESIGN: This is a single-center, randomized controlled trial of infants 240/7 to 276/7 weeks' gestation who received UCM versus ICC. In the experimental group, 18 cm of the umbilical cord was milked three times. The primary aim was to assess the initial hemoglobin and to assess the number of blood transfusions received in the first 28 days after birth. Secondary outcomes were also assessed, including intraventricular hemorrhage (IVH). A priori, neurodevelopmental follow-up was planned at 15 to 18 months corrected gestational age (CGA). RESULTS: Baseline characteristics for 56 enrolled infants were similar in both groups with a mean gestational age of 26.1 ± 1.2 weeks and a mean birth weight of 815 ± 204 g. There were no differences in the mean initial hemoglobin in the UCM group when compared with the ICC group, 13.7 ± 2.0 and 13.8 ± 2.6 g/dL, respectively (p = 0.95), with no differences in median number of blood transfusions after birth between the ICC group and the UCM group, 2 (interquartile range [IQR]: 1-4) versus 2.5 (IQR: 1-5) (p = 0.40). There was also no difference in the rate of severe IVH. At 15 to 18 months CGA, there were no differences in death or disability in the ICC group compared with the UCM group (26 vs. 22%; p = 1.0) and no differences in neurodevelopmental outcomes. CONCLUSION: In a randomized trial of ICC versus UCM in extremely preterm infants, no differences were seen in initial hemoglobin or number of blood transfusions. KEY POINTS: · Umbilical cord milking may be an alternative to delayed cord clamping, but its safety and efficacy are not established in extremely premature infants.. · There are minimal available published data on the longer term neurodevelopmental outcomes in extremely premature infants who receive umbilical cord milking compared with immediate clamping.. · We did not find a significant difference in the primary outcomes of initial hemoglobin and blood transfusions between the groups, nor did we find a difference in severe IVH with umbilical cord milking..

Sun Protection Outreach Teaching by Students (SPOTS)-Evaluating the Efficacy of Skin Cancer Prevention Education for Adolescents.

BACKGROUND: The Sun Protection Outreach Teaching by Students (SPOTS) program addresses an unmet need by training medical students to teach adolescents about skin cancer prevention and early detection. OBJECTIVE: To measure (1) changes in adolescents' knowledge, attitudes, and behaviors regarding sun protection and (2) the impact on medical students' confidence in skin cancer preventive counseling. METHODS: Pre-SPOTS and 1-month post-SPOTS program surveys were completed by adolescent participants and medical student instructors. RESULTS: Amongst adolescent students, analysis of 1,142 pre-program surveys and 618 post-program surveys revealed statistically significant improvements in knowledge, attitudes, and behaviors. Among the favorable results, 26%, 41%, and 20% improvements over baseline were observed in SPF knowledge, preference for natural untanned skin, and intent to wear sunscreen, respectively (p < .001). One-third of adolescents reported having tried to increase sunscreen use. Amongst medical students, analysis of 78 pre-teaching and 74 post-teaching surveys revealed an increase in feeling "very confident" in counseling patients, from 23% pre-teaching to 82% post-teaching (p < .001). CONCLUSION: SPOTS demonstrated a dual benefit to adolescents and medical students. The program is available for dermatologists to implement in their communities.

Dermatopathologist assessment of "pathologist-to-dermatologist" communication for dermatopathology services.

BACKGROUND: While patients are the ultimate beneficiaries of pathology services, pathologist to clinician communication is an essential component of excellent patient care. OBJECTIVE: To survey dermatologists on how well pathologists communicate with them and to assess which aspects of pathologists' communication skills are deemed most significant to dermatologists, stratified by practice type. METHODS: A survey-based instrument was developed and sent to dermatologists through various email listservs. Of the approximately 400 potential Association of Professors of Dermatology respondents, 64 returned the survey questionnaire (response rate 16%). Of the 79 state and regional dermatologic societies, seven agreed to distribute the survey on their listservs (response rate 9%). RESULTS: Surveyed dermatologists believe that the pathologists with whom they work are meeting expectations in the areas of diagnostic accuracy, communicating pertinent information in a timely fashion, integrating written pathology reports into the electronic medical record, and making a clinically meaningful histopathologic interpretation. Discussion of cost of ancillary testing is an area of improvement. University affiliated dermatologists are more likely to use electronic medical records as their predominant mode of communication compared to community dermatologists with and without academic affiliations. Community dermatologists are more likely to use faxed written pathology reports as their predominant mode of communication. CONCLUSION: Physician-to-physician communication is a key component of effective patient care. When it comes to dermatopathology services, dermatologists appear overall satisfied with the indicators examined, however, potential opportunities for improvement exist.

Patient-Centered Outcomes for Skin Cancer Management: Utilization of a Patient Delphi Process to Identify Important Treatment Themes.

BACKGROUND: Patient-reported outcomes are critical to research directed at maximizing patient benefit. The outcomes patients consider most relevant in the treatment of skin cancer have not been directly investigated. OBJECTIVE: To develop a ranked list of outcomes deemed most important by patients with skin cancer through a proctored Delphi process. METHODS: Twenty-one patients with a history of skin cancer volunteered to participate in the patient summit. The patient members participated in a guided discussion to generate a long list of potentially relevant outcomes. The list was then condensed and ranked through 2 rounds of a proctored Delphi process. RESULTS: Patients were diverse in their skin cancer histories and complexities, ages, and states of residence. Twelve themes were rated as highly important by 70% or more of participants. Most of these themes related to patient education and the collaborative nature of the physician-patient relationship. Fear of recurrence and cosmetic outcome were also highly rated. Limitations include a preponderance of older patients and patients from the midwest and northeast. CONCLUSION: Patients with skin cancer overwhelmingly prioritize a shared decision-making process, in which they are actively engaged and value detailed education regarding their disease. This should inform future research directed at skin cancer treatment and current physician-patient interactions.

Physician-Centered Outcomes for Skin Cancer Treatment: A Single-Day Modified Delphi Process to Assess the Importance of Themes in Skin Cancer Management.

BACKGROUND: Success in skin cancer treatment is determined through outcome measurement. Patients and physicians may prioritize different outcomes of care, and identification of such may enhance patient-centered care. OBJECTIVE: To identify gaps between patient and physician attitudes toward skin cancer outcomes. MATERIALS AND METHODS: A single-day, 21-patient, modified, in-person Delphi process to solicit and rate the importance of skin cancer-related outcomes was conducted. Twelve masked dermatologic surgeons rated patient-generated outcomes in a 2-round modified Delphi process. Each item was rated on a 1 to 9 scale (1, least important; 9, most important) using the Qualtrics web platform (Qualtrics, Provo, UT). Results of the physician ratings were compared with the patient ratings. RESULTS: A list of 53 skin cancer treatment-related themes and outcomes was generated. Eight items were ranked by physicians as "very high" (>80% importance), 5 as "high" (>70% importance), 19 as intermediate, and 21 as low. The physician and patient panels' ratings were concordant for 56% of items, whereas 7 outcome items showed a 2-category discordance. CONCLUSION: Physicians and patients were concordant regarding skin cancer treatment on multiple spheres. Areas of discordance include patient fear of unknown future risk, recurrence, or empowering patients to make treatment choices, and may be areas of continued improvement for delivery of patient-centered care.

Description of Venous Thromboembolism in Hospitalized Patients With Metastatic Cancer: A National Sample.

Background: This study aimed to determine patient-, tumor-, and hospital-level characteristics associated with venous thromboembolism (VTE), and to assess the impact of VTE on in-hospital mortality and length of hospital stay in hospitalized patients with metastatic cancer. Methods: Using the Nationwide Inpatient Sample database, a cross-sectional analysis was performed of patients aged ≥18 years with at least 1 diagnosis of primary solid tumor and subsequent secondary or metastatic tumor between 2008 and 2013. Results: Among 850,570 patients with metastatic cancer, 6.6% were diagnosed with VTE. A significant trend for increasing VTE rates were observed from 2008 to 2013 (5.7%-7.2%; P<.0001). Using an adjusted multilevel hierarchical regression model, higher odds of VTE were seen among women (odds ratio [OR], 1.04; 95% CI, 1.02-1.06), black versus white patients (OR, 1.14; 95% CI, 1.11-1.18), and those with an Elixhauser comorbidity index score of ≥3 (OR, 2.50; 95% CI, 2.38-2.63). Hospital-level correlates of VTE included treatment in a teaching hospital (OR, 1.05; 95% CI, 1.01-1.11) and an urban location (OR, 1.18; 95% CI, 1.09-1.27), and admission to hospitals in the Northeast (OR, 1.16; 95% CI, 1.08-1.24) and West (OR, 1.09; 95% CI, 1.03-1.16) versus the South. Patients with metastasis to the liver, brain, or respiratory organs and those with multiple (≥2) metastatic sites had higher odds of VTE, whereas those with metastasis to lymph nodes and genital organs had lower odds. Patients diagnosed with versus without VTE had higher odds of in-hospital mortality (OR, 1.50; 95% CI, 1.38-1.63) and prolonged hospital stay (OR, 1.65; 95% CI, 1.57-1.73). Conclusions: The frequency of VTE in patients with metastatic cancer is increasing. Patient characteristics, hospital factors, and site of metastasis independently predict the occurrence of VTE and allow for better stratification of patients with cancer according to their VTE risk.

Do Patterns of Reconstruction Choices After Mohs Surgery Vary by Specialty? A Pilot Study of Mohs Surgeons and Facial Plastic Surgeons.

BACKGROUND: Differences in approach to repair a specified defect after Mohs micrographic surgery (MMS) between specialties have not been previously examined. OBJECTIVE: To assess the difference in frequency of which reconstruction repairs are selected after MMS, among Mohs surgeons and facial plastic surgeons (FPS), and evaluate whether the level of satisfaction with the final repair outcome differed between specialties. MATERIALS AND METHODS: The study was approved by the Saint Louis University Institutional Review Board. A link to the survey was distributed to members of American College of Mohs Surgery (ACMS) and American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), between January and May 2016. RESULTS: The reconstructive procedure selected most often ("top choice") was not significantly different between Mohs surgeons and FPS for the majority of the images. There was no material difference in how dermatologists and FPS rate the aesthetic outcome of the 3 presented closure types, with the exception of one closure type-nose with graft. CONCLUSION: Mohs surgeons were found to more likely cluster around a single preference for their reconstruction technique compared with FPS, in which a higher percentage of surgeons also selected other options.

Bending the Arc of the Trilobed Flap Through External Interlobe Angle Inequality.

BACKGROUND: The trilobed flap is a useful repair option for distal nasal defects. In certain cases, however, the placement of its quaternary defect may risk compression of the internal nasal valve or induction of ectropion. In this study, we propose a modified design of the trilobed flap, which uses unequal external interlobe angles. OBJECTIVE: To present the design principles and results of our modified trilobed flap for the reconstruction of difficult distal nasal Mohs defects. MATERIALS AND METHODS: Mohs defects of 26 patients were reconstructed (21 with long-term follow-up) using our modified trilobed flap over 1 year. Two independent masked raters graded postoperative photographs for alar symmetry and overall cosmesis. RESULTS: Median alar symmetry scores were excellent and overall cosmesis grades were between excellent and very good. CONCLUSION: The modified trilobed flap with unequal external angles offers an excellent option for reconstruction of Mohs defect of the distal nose that may not be well-suited for other repairs. Over 1 year, 21 modified trilobed repairs were performed with overall excellent outcomes.

Patients' Body Image Improves After Mohs Micrographic Surgery for Nonmelanoma Head and Neck Skin Cancer.

BACKGROUND: Most skin cancers occur on the head and neck, areas of the body that are significant to an individual's body image (BI) perception. Poor BI is a robust risk factor for depression and decreased quality of life. Thus, patients with nonmelanoma head and neck skin cancer (NMHNSC) may be more vulnerable to BI disturbance and the negative sequelae of poor BI. OBJECTIVE: Describe the nature of BI concerns in patients diagnosed with NMHNSC and assess how BI changes with treatment. METHODS AND MATERIALS: Patients undergoing Mohs micrographic surgery (MMS) for NMHNSC completed assessments of BI and well-being before (N = 239) and 6 months after (N = 80) treatment with MMS. Demographic and tumor data were gathered through retrospective chart review. RESULTS: Body image improved significantly 6 months after MMS, and the magnitude of this change was large (η = 0.18). Repair length (length of final scar irrespective of repair type) >4 cm predicted poorer BI at 6-month follow-up. CONCLUSION: Patients' BI improves after treatment with MMS for NMHNSC.

A Novel, Disease-Specific Self-Report Instrument to Measure Body Image Concerns in Patients With Head and Neck Skin Cancer.

BACKGROUND: Skin cancer commonly occurs on areas that are salient to body image perception (i.e., head and neck). Patients with head and neck skin cancer (HNSC) may experience negative body image perceptions related to their disease, which is concerning, given the numerous negative sequelae of poor body image. However, there are no existing disease-specific measures of body image concerns in HNSC. OBJECTIVE: To develop and examine the psychometric properties of a brief self-report, disease-specific measure of body image concerns in patients with HNSC-the Body Image Questionnaire (BIQ). MATERIALS AND METHODS: Patients with HNSC completed the BIQ before (n = 239) and 6 months after (n = 80) treatment with Mohs micrographic surgery. Analyses examined the internal consistency, convergent validity, and factor structure of the BIQ. RESULTS: Internal consistency reliability was acceptable, and the measure demonstrated convergent validity with well-being. Four dimensions underlie the BIQ: appearance satisfaction, appearance avoidance, head/neck/skin-specific dissatisfaction, and perceived change. CONCLUSION: The BIQ is a valid and internally reliable disease-specific instrument that measures body image concerns in patients with HNSC.

Positive Outcomes of Optimizing Student-Preceptor Continuity in a Traditional Block Clerkship.

PROBLEM: Student-preceptor discontinuity during 3rd-year clerkships limits the quality and quantity of supervision, teaching, and feedback. Although longitudinal integrative clerkships increase continuity and are associated with improved student and preceptor experience, they require schoolwide curricular reform. Alternative innovations enhancing student-preceptor relationships within the constraints of a traditional block clerkship may demonstrate similar benefits. INTERVENTION: We piloted a continuity-enhanced general pediatric ambulatory schedule during 2 consecutive clerkship blocks in 2013. Students in the continuity-enhanced model (n = 29) were assigned 1-3 primary clinic preceptors, whereas those in the traditional model (n = 30) worked with 5-8. Data were gathered from student assessments and anonymous student and preceptor surveys. We used t and Fisher's exact tests to compare the two groups and performed thematic analysis of free-text survey comments. CONTEXT: Our school utilizes a block clerkship model with approximately 30 students rotating through the pediatric clerkship every 8 weeks. During the 3-week ambulatory portion, students spend 8 half days in the general pediatric ambulatory clinic. At the conclusion of each clinic, attendings completed brief student evaluation cards. Traditionally, student and attending schedules were created independently, resulting in transient supervisory relationships and dissatisfaction with clinical engagement, feedback, and evaluation. OUTCOME: Seventy-three percent (43/59) of the students completed the survey. Ten general ambulatory attendings collectively completed 87.5% (35/40) of the monthly surveys. Continuity students received significantly more narrative evaluation comments (10.6 vs. 5.8, p <. 001) from general ambulatory clinic attendings and were more likely to have at least one general ambulatory clinic attending endorse being able to provide meaningful feedback and evaluation (n = 29, 100% vs. n = 20, 66.7%, p <. 001). Continuity students were also more likely to endorse being able to ask at least one of these attendings for a letter of recommendation (71.4% vs. 9.1%, p <. 001) and to have at least one general ambulatory clinic attending endorse being able to provide a meaningful letter of recommendation if asked (62.1% vs. 3.3%, p <. 001). Students (88.4%) and attendings (85.7%) preferred the continuity-enhanced schedule. The most frequent theme of both student and attending free-text survey remarks were relationships and assessment. LESSONS LEARNED: Intentional scheduling of clerkship students to enhance preceptor continuity resulted in significant positive outcomes echoing the relationship-based educational benefits of longitudinal clerkships, particularly in regards to student assessment and feedback. Clerkship directors and other medical educators should consider implementing small changes within block clerkships to maximize student-preceptor continuity.

Variation in Pediatric Organ Donor Management Practices Among US Organ Procurement Organizations.

INTRODUCTION: Reports of actual pediatric organ donor management practice among US organ procurement organizations are sparse, and the use of standardized management guidelines is unknown. A recent consensus statement from the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations offers guidelines for the management of the pediatric organ donor. RESEARCH QUESTION: To describe the use of guidelines and routine practices in the management of the pediatric organ donor with respect to hemodynamics, lung and ventilator management, fluid and electrolytes, hormonal replacement therapy, the use of blood products, thermoregulation, and prophylactic antibiotics. DESIGN: Cross-sectional observational study using a survey and follow-up telephone interview with respondents from all 58 US organ procurement organizations. RESULTS: All 58 US Organ Procurement Organizations participated. A majority employed written guidelines for the management of pediatric donor hemodynamics, thermoregulation, fluids, and electrolytes. Management of blood products, the lung, and mechanical ventilation were less commonly committed to written guidelines, but common practices were described. All used various forms of hormonal replacement therapy and the majority administered empiric antibiotic therapy. Wide variation was observed in the management of the lung, mechanical ventilation, and glycemic control. DISCUSSION: Most OPOs used forms of standardized donor management for the pediatric organ donor although variation in the content of that management exists. Barriers to an evidence-based approach to the pediatric donor need to be determined and addressed.

A 30-Minute, Monthly, Live, Webinar-Based Journal Club Activity Alters the Self-Reported Behaviors of Dermatologic Surgeons.

BACKGROUND: Journal clubs provide a way to communicate advances in recent literature. In outpatient surgical subspecialties, such as dermatologic surgery, physicians may face challenges in finding or attending meetings pertinent to their practice. OBJECTIVE: To assess the utility of a live web-based journal club in dermatologic surgery. MATERIALS AND METHODS: Monthly 30-minute journal club sessions covering 5 to 6 scholarly articles. Anonymous surveys were used to evaluate the utility and self-reported learning associated with each meeting. RESULTS: From December 2012 to February 2015, 117 articles were reviewed. Survey data were acquired monthly, apart from 5 months of missing data. On average, the survey response rate was 37% (range: 7%-82%), with an average of 17 participants per monthly session (range: 9-25). The mean monthly usefulness score was 83.7 (101-point scale), with participants scoring their likelihood of returning in the future as 96.2 (0 = not likely, 100 = extremely likely). At each session, a mean of 68% of participants felt that at least one article would change their practice of medicine. CONCLUSION: A monthly online and telephonic journal club may be a practical and effective way to inform dermatologic surgeons of new developments in high impact literature and may influence improvements in individual practice.

p53 Is a Helpful Marker in Distinguishing Langerhans Cell Histiocytosis From Langerhans Cell Hyperplasia.

Langerhans cell histiocytosis (LCH) is a proliferative disorder of Langerhans cells that can be challenging to distinguish histologically from Langerhans cell (LC) hyperplasia, seen in a variety of inflammatory dermatoses. Lesional cells in both entities demonstrate positive staining for CD1a and S100. Previous studies have demonstrated positive staining of fascin, CD31, and p53 in cases of LCH, but currently, no studies have compared the staining profiles of these markers between LCH and LC hyperplasia. The authors compared immunohistochemical staining profiles of LCH (n = 15) and various inflammatory dermatoses with LC hyperplasia (n = 15) using fascin, CD31, and p53. Fascin, CD31, and p53 were graded as a percentage of CD1a staining cells in the epidermis and dermis of each specimen. Fascin showed no significant differences in staining between the 2 entities. CD31 was positive in the dermal infiltrate in 40% of cases of LCH and negative in all cases of LC hyperplasia. p53 was positive in the epidermal infiltrate in 50% of cases of LCH, and positive in the dermal infiltrate in 93% of cases of LCH, whereas negative in all cases of LC hyperplasia. Fascin was not a helpful marker in distinguishing LCH from LC hyperplasia. CD31, if positive in the dermal infiltrate, is suggestive of a diagnosis of LCH, but exhibits a relatively low sensitivity for this purpose. p53 proved to be a helpful and accurate diagnostic immunohistochemical stain when distinguishing between LCH and LC hyperplasia.

Procedures in the 1st year of life for children with trisomy 13 and trisomy 18, a 25-year, single-center review.

Care of the child born with trisomy 13 or 18 has evolved over the past few decades, leading to increased healthcare utilization. We hypothesized that there has been an increase in procedures across all intensity types, including major, invasive procedures. We performed a retrospective-cohort study of children with trisomy 13 or 18 from 1990 to 2014 in a quaternary, free-standing children's hospital. Children were identified using ICD-9 billing diagnoses. Procedures were identified during these encounters and categorized by intensity (major, intermediate, or minor). One hundred thirty-two children with trisomy 13 or 18 were identified. In children with trisomy 13, major procedures increased from period 1 (1990-1997) to period 3 (2006-2013) from 0.11 to 0.78 procedures per patient. For trisomy 18, the increase between the time periods was from 0.14 to 1.33 procedures per patient. By the end of the study period, nearly all trisomy 13 patients had a major procedure and the majority of those with trisomy 18 had undergone a major procedure. Estimated 1-year survival for those with a major procedure was 30% and 22% for trisomies 13 and 18, respectively. In conclusion, there was an increasing rate of procedures per patient of all intensity levels over the 25-year study period. Given differences in characteristics in those with trisomies 13 and 18, and effects of intervention on survival, an individualized approach to care of these patients should be employed by parents and healthcare providers, using factors such as trisomy type, infant gender, co-morbidities, and parental preference. © 2016 Wiley Periodicals, Inc.