COVID-19: Perspectives From Frontline Critical Care Nurses in New York.

New York City quickly became the epicenter of coronavirus disease-2019 (COVID-19) in early March of 2020. While hospitals were aware of the potential of COVID-19, the volume of critically ill patients that flooded the hospitals in the New York City area was clearly not anticipated. Hospital staff worked quickly to create COVID-19-free areas, but were overcome with the volume of COVID-positive critically ill patients. Many newly admitted patients required respiratory support with mechanical ventilation. As Governor Cuomo issued executive orders to stay at home in mid-March, some patients were afraid to go into hospitals despite symptoms of respiratory distress. Once these patients came to the hospital, they were often critically ill. Emergency departments and intensive care units filled rapidly, overwhelming staff and equipment needs with such things as pumps, dialysis machines, medications, and personal protective equipment. Plans for the day were disrupted with frequent rapid response calls and the need for additional beds. Key issues that confronted the COVID-19 response in critical care units at NYU Langone Health included communication, patient and staff safety.

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.

Patient satisfaction and physician productivity in shared medical appointments for vitiligo.

BACKGROUND: The shared medical appointment (SMA) allows patients with a similar diagnosis to be simultaneously cared for and educated by 1 provider, which has had success in dermatology and other fields of specialty. The SMA provides a potential solution to improve patient access to dermatologists. OBJECTIVE: The purpose of this study was to implement the SMA for patients with vitiligo and compare it to traditional appointments with regard to patient satisfaction, time to appointment, number of new patients seen per month, and generated revenue. METHODS: A vitiligo SMA was implemented, and a 12-question survey was used to assess satisfaction in both SMA and traditional appointment settings. Satisfaction, revenue, and appointment logistic data for SMAs were compared with those for traditional appointments for new patients. RESULTS: Patients were highly satisfied with both SMAs and traditional appointments (P > .05). Time to appointment was faster for the SMA, and significantly more new patients were seen monthly with the SMA (P = .009). LIMITATIONS: Limitations include small sample size, inability to correlate responder characteristics with survey responses, potential response bias, and selection bias due to absence of randomization. CONCLUSION: SMAs were successful in a vitiligo clinic for both patient and provider. The SMA is a solution to improve access to dermatologists without compromising patient benefit, experience, or satisfaction.

Approaches to Perineural, Lymphovascular, and Single-Cell Disease.

BACKGROUND: Mohs micrographic surgeons should be adept in identifying and managing perineural invasion (PNI), lymphovascular invasion (LVI), and single-cell spread (SCS), features denoting high-risk behavior of basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC) and microcystic adnexal carcinoma (MAC). OBJECTIVE: The purpose of this article is to review the literature and guidelines regarding the diagnosis of PNI, LVI, and SCS in BCC, cSCC, and MAC and examine the role of advanced diagnostic studies, adjuvant therapy, and reconstructive techniques of these high-risk tumors. MATERIALS AND METHODS: We performed a literature search including the following terms: PNI, LVI, SCS, BCC, cSCC, keratinocyte carcinoma, MAC, sentinel lymph node biopsy, radiation, chemotherapy, and staging. Relevant studies, case reports, and review articles were included, as well as National Comprehensive Cancer Network guidelines. RESULTS: Pancytokeratin immunohistochemistry may aid in the diagnosis of high-risk features of BCC and cSCC. Reconstruction of the Mohs defect should be carefully considered to allow for thorough inspection. Radiation therapy should be considered as an adjuvant treatment option for high-risk cSCC and BCC. Close surveillance for recurrence is warranted. CONCLUSION: The Mohs surgeon should be competent in identification of high-risk tumors and to understand how best to manage, further treat, and follow these tumors.

Health Technology Agency insights: informing modification of a qualitative benefit risk framework for Health Technology Reassessment of prescription medications.

OBJECTIVES: This study's intent was to determine if a qualitative benefit risk framework could be used or modified to further enable Health Technology Reassessment (HTR) of prescription medicine recommendations. The purpose of this research was to understand Canadian Health Technology Agency assessors past experiences and insights to inform any modifications to the Universal Methodology for Benefit-Risk Assessment (UMBRA) qualitative framework. The UMBRA framework consists of an eight-step process, used during the assessment phase, to aid in decision making and dissemination. METHODS: A qualitative descriptive study was conducted and included a purposeful, criterion-based sample of eight assessors who had participated in Health Technology Assessment (HTA) or HTR for prescription medicines or in qualitative decision-making frameworks. RESULTS: Participant interviews lead to four common themes: "adoption of a qualitative benefit risk framework," "data (either too much or not enough)," "importance of incorporating stakeholder values," and "feasibility of the UMBRA framework." Methodological challenges with HTR were highlighted including the lack of clinical outcome data and the ability to compare clinically relevant meaningful differences. The implementation of a ranking or weighing process found within the UMBRA framework was not favored by half of the participants. CONCLUSIONS: Research participants did not consider all steps of the UMBRA framework to be transferable to the assessment phase of HTR given the need for simplicity, resource efficiency, and stakeholder input throughout the process. The assessor experiences and insights and the resultant key themes can be used in future research to aid in the development of a qualitative recommendation framework for HTR.

DRUG DISINVESTMENT FRAMEWORKS: COMPONENTS, CHALLENGES, AND SOLUTIONS.

OBJECTIVES: Value assessments of marketed drug technologies have been developed through disinvestment frameworks. Components of these frameworks are varied and implementation challenges are prevalent. The objective of this systematic literature review was to describe disinvestment framework process components for drugs and to report on framework components, challenges, and solutions. METHODS: A systematic literature search was conducted using the terms: reassessment, reallocation, reinvestment, disinvestment, delist, decommission or obsolescence in MEDLINE, EMBASE, NLM PubMed, the Cochrane Library, and CINAHL from January 1, 2000, until November 14, 2015. Additional citations were identified through a gray literature search of Health Technology Assessment international (HTAi) and the International Network of Agencies for Health Technology Assessment (INAHTA) member Web sites and from bibliographies of full-text reviewed manuscripts. RESULTS: Sixty-three articles underwent full text review and forty were included in the qualitative analysis. Framework components including disinvestment terms and definitions, identification and prioritization criteria and methods, assessment processes, stakeholders and dissemination strategies, challenges, and solutions were compiled. This review finds that stakeholders lack the political, administrative, and clinical will to support disinvestment and that there is not one disinvestment framework that is considered best practice. CONCLUSIONS: Drug technology disinvestment components and processes vary and challenges are numerous. Future research should focus on lessening value assessment challenges. This could include adopting more neutral framework terminology, setting fixed reassessment timelines, conducting therapeutic reviews, and modifying current qualitative decision-making assessment frameworks.

Avoiding Medical Errors in Cutaneous Site Identification: A Best Practices Review.

BACKGROUND: Although the field of dermatology has a relatively low incidence of medical errors, dermatologic surgery is a major area where medical errors occur. OBJECTIVE: The purpose of this article is to catalog the many cutaneous site identification techniques used by practitioners and determine which techniques are most evidence based. MATERIALS AND METHODS: A comprehensive literature review of cutaneous surgical site identification techniques and medical errors in dermatology. RESULTS: Wrong-site surgery often occurs because of an inability to identify the surgical site because of factors such as inadequate documentation from referring physicians, well-healed scars obscuring the biopsy site, and a patient's inability to visualize the surgical site. Practitioners use techniques such as photography, dermabrasion, written descriptions using anatomic landmarks, and site identification protocols for surgical site identification. CONCLUSION: Site identification remains a challenge for dermatologists and is a leading cause of medical errors in this field. Patients are often unreliable in their ability to identify biopsy sites; therefore, practitioners must take a proactive role to ensure that medical errors do not occur. This article provides a thorough description and evaluation of current site identification techniques used in dermatology with the aim to improve quality of care and reduce medical errors.

Single-Cell Squamous Carcinoma: An Underreported High-Risk Variant.

BACKGROUND: There is increasing interest in establishing diagnostic and treatment guidelines for high-risk squamous cell carcinoma (SCC). Single-cell SCC has been recognized as a high-risk subtype but continues to be a less commonly reported and more poorly understood variant. OBJECTIVE: To present the current literature on single-cell SCC. MATERIALS AND METHODS: A review of the literature on single-cell squamous cell carcinoma. RESULTS: There are fewer than 100 cases of single-cell SCC in the literature. The reporting studies demonstrate an increase in the risk of metastasis compared with non-single-cell tumors. Confounding variables reported include other coexisting high-risk features: diameter >2 cm, depth >6 mm, and difficulty detecting single tumor cells. It is therefore unclear whether single-cell SCC is an independent risk factor for recurrence and regional spread. Studies have described use of immunostaining as a means to improve tumor detection. CONCLUSION: Single-cell SCC continues to be an underreported SCC variant. Given its apparent aggressive behavior, more studies are warranted to better understand its tumor biology and behavior and to improve patient outcomes. Based on our present knowledge, complete tumor excision with or without the aid of immunostaining and use of multidisciplinary care are recommended.

A Retrospective Study of Nail Squamous Cell Carcinoma at 2 Institutions.

BACKGROUND: Squamous cell carcinoma (SCC) of the nail is infrequently reported in the medical literature and its causes are poorly understood. Studies have shown strong associations with immunosuppression, tobacco use, toxin/radiation exposure, and trauma. Common treatments include Mohs surgery and digital amputation. OBJECTIVE: Review a series of nail SCCs treated at 2 institutions. Outcomes evaluated included rates of recurrence and disease progression/metastasis after treatment. MATERIALS AND METHODS: A retrospective review of patients treated between 2005 and 2008. Medical record review and phone call follow-up using a standardized questionnaire were used. RESULTS: Forty-two tumors were identified in 34 patients. Twenty-seven patients were male (79% CI, 62%-91%) and most tumors were located on the fingernails (39/42; 91% CI, 81%-99%). Twenty-four of 39 tumors (62% CI, 45%-77%) were on the nondominant hand. The middle third finger was the most frequent digit affected (16/42). Common symptoms reported were nail dystrophy (31/42; 74% CI, 58%-86%), followed by onycholysis (22/42; 52% CI, 36%-68%). Most tumors (35/42; 83% CI, 69%-93%) were treated with Mohs surgery. CONCLUSION: Nail SCC is found nearly exclusively in adults and predominantly in men. There are multiple effective treatment possibilities including Mohs surgery, distal digital amputation, and early evidence suggesting radiotherapy.

To scoop or not to scoop: the diagnostic and therapeutic utility of the scoop-shave biopsy for pigmented lesions.

BACKGROUND: Concern over transection of melanomas has inhibited many practitioners from using the scoop-shave for removal of pigmented lesions. OBJECTIVE: To assess the safety and efficacy of the scoop-shave for pigmented lesions. MATERIALS AND METHODS: The practitioner's clinical diagnosis, intent (sample or completely remove), and removal technique (excision, punch, shave biopsy, or scoop-shave) were recorded. Pathology results including the status of the peripheral and deep margins were subsequently documented. RESULTS: Over an 8-month period, 333 procedures were performed. Of the 11 melanomas (6 in situ and 5 invasive) removed by the scoop-shave, none had positive deep margins and 6 (2 in situ and 4 invasive) were completely removed. One of the 50 dysplastic nevi removed by scoop-shave had a positive deep margin (moderately dysplastic). Forty-six dysplastic nevi were completely removed by the scoop-shave. When the practitioner's intent was "complete removal," the lesion was completely removed 73.1% of the time by scoop-shave, 91% by standard excision, 18.1% by shave biopsy, and 78.6% by punch excision (p < .0001). CONCLUSION: The scoop-shave is a safe and effective technique for diagnosis and treatment of melanocytic lesions.

Dermatologic surgery and cosmetic procedures during pregnancy and the post-partum period.

Dermatologic surgery is changed in the pregnant and postpartum patient. The physiologic changes associated with pregnancy require attention to the timing of surgery as well as the positioning and technique to maximize the outcome for the patient. The surgeon must also remember the risks to the fetus or nursing newborn in planning any surgical procedure. This is the one time when there is more than one patient in every procedure. This article will review the timing of surgery, tumors of pregnancy, surgical positioning, local anesthetics, surgical technique, and cosmetic procedures. This information should help provide a safe surgical procedure for the mother and the child.

Design and Validation of a Handheld Optical Polarization Imager for Preoperative Delineation of Basal Cell Carcinoma.

BACKGROUND: Accurate removal of basal cell carcinoma (BCC) is challenging due to the subtle contrast between cancerous and normal skin. A method aiding with preoperative delineation of BCC margins would be valuable. The aim of this study was to implement and clinically validate a novel handheld optical polarization imaging (OPI) device for rapid, noninvasive, in vivo assessment of skin cancer margins. METHODS: The handheld imager was designed, built, and tested. For clinical validation, 10 subjects with biopsy-confirmed BCC were imaged. Presumable cancer margins were marked by the study surgeon. The optical images were spectrally encoded to mitigate the impact of endogenous skin chromophores. The results of OPI and of the surgeon's preoperative visual assessment were compared to clinical intraoperative histopathology. RESULTS: As compared to the previous prototype, the handheld imager incorporates automated image processing and has 10-times shorter acquisition times. It is twice as light and provides twice as large a field of view. Clinical validation demonstrated that margin assessments using OPI were more accurate than visual assessment by the surgeon. The images were in good correlation with histology in 9 out of 10 cases. CONCLUSIONS: Handheld OPI could improve the outcomes of skin cancer treatments without impairing clinical workflows.

Adverse effects of ultraviolet radiation from the use of indoor tanning equipment: time to ban the tan.

The incidence of melanoma skin cancer is increasing rapidly, particularly among young women in the United States. Numerous studies have documented an association between the use of indoor tanning devices and an increased risk of skin cancer, especially in young women. Studies have shown that ultraviolet exposure, even in the absence of erythema or burn, results in DNA damage. Countries and regulatory bodies worldwide have recognized the health risks associated with indoor tanning. In the United States, 32 states have passed legislation to regulate the indoor tanning industry, but there is an urgent need to restrict the use of indoor tanning devices at the federal level. The Food and Drug Administration is currently reviewing the classification of these devices. For all of these reasons, the Food and Drug Administration should prohibit the use of tanning devices by minors and reclassify tanning devices to at least class II to protect the public from the preventable cancers and other adverse effects caused by ultraviolet radiation from indoor tanning.

Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications.

BACKGROUND: Few prospective studies have evaluated the safety of dermatologic surgery. OBJECTIVE: We sought to determine rates of bleeding, infection, flap and graft necrosis, and dehiscence in outpatient dermatologic surgery, and to examine their relationship to type of repair, anatomic location of repair, antibiotic use, antiplatelet use, or anticoagulant use. METHODS: Patients presenting to University of Massachusetts Medical School Dermatology Clinic for surgery during a 15-month period were prospectively entered. Medications, procedures, and complications were recorded. RESULTS: Of the 1911 patients, 38% were on one anticoagulant or antiplatelet medication, and 8.0% were on two or more. Risk of hemorrhage was 0.89%. Complex repair (odds ratio [OR] = 5.80), graft repair (OR = 7.58), flap repair (OR = 11.93), and partial repair (OR = 43.13) were more likely to result in bleeding than intermediate repair. Patients on both clopidogrel and warfarin were 40 times more likely to have bleeding complications than all others (P = .03). Risk of infection was 1.3%, but was greater than 3% on the genitalia, scalp, back, and leg. Partial flap necrosis occurred in 1.7% of flaps, and partial graft necrosis occurred in 8.6% of grafts. Partial graft necrosis occurred in 20% of grafts on the scalp and 10% of grafts on the nose. All complications resolved without sequelae. LIMITATIONS: The study was limited to one academic dermatology practice. CONCLUSION: The rate of complications in dermatologic surgery is low, even when multiple oral anticoagulant and antiplatelet medications are continued, and prophylactic antibiotics are not used. Closure type and use of warfarin or clopidogrel increase bleeding risk. However, these medications should be continued to avoid adverse thrombotic events.

Adverse effects of ultraviolet radiation from the use of indoor tanning equipment: time to ban the tan.

The incidence of melanoma skin cancer is increasing rapidly, particularly among young women in the United States. Numerous studies have documented an association between the use of indoor tanning devices and an increased risk of skin cancer, especially in young women. Studies have shown that ultraviolet exposure, even in the absence of erythema or burn, results in DNA damage. Countries and regulatory bodies worldwide have recognized the health risks associated with indoor tanning. In the United States, 32 states have passed legislation to regulate the indoor tanning industry, but there is an urgent need to restrict the use of indoor tanning devices at the federal level. The Food and Drug Administration is currently reviewing the classification of these devices. For all of these reasons, the Food and Drug Administration should prohibit the use of tanning devices by minors and reclassify tanning devices to at least class II to protect the public from the preventable cancers and other adverse effects caused by ultraviolet radiation from indoor tanning.