The use of oral midazolam for perioperative anxiolysis of healthy patients undergoing Mohs surgery: conclusions from randomized controlled and prospective studies.

BACKGROUND: Anxiety can complicate any outpatient procedure by causing elevation in blood pressure and heart rate with resultant increase in intraoperative and postoperative bleeding. Anxiety may also reduce patient satisfaction with the surgical experience. Midazolam is an efficacious short-acting benzodiazepine with an excellent safety record. However, little experience is documented on the use of midazolam in outpatient dermatologic surgery. OBJECTIVE: To establish the safety and efficacy of oral midazolam in healthy patients undergoing Mohs micrographic surgery. METHODS: Patients undergoing outpatient Mohs surgery were randomized in a double-blind, placebo-controlled study of single-dose midazolam for efficacy and safety in producing anxiolysis of short duration. A subpopulation of patients was evaluated prospectively in a nonrandomized arm of the study. Data on vital signs, anxiety, adverse events, and overall satisfaction were collected and compared using analysis of covariance model. RESULTS: Forty-four patients were randomized and 31 patients were enrolled in the prospective arm. Socioeconomic and surgical characteristics were similar among the groups. At 60 minutes, there was a clinically and statistically significant reduction in anxiety and alertness in both randomized and prospective arms. There were no major adverse events. Patients in all 3 groups were equally satisfied with their experience. LIMITATIONS: Few patients with high perioperative anxiety were willing to participate in a randomized controlled trial of anxiolytic medication. CONCLUSIONS: Midazolam is safe and efficacious in perioperative anxiolysis for healthy patients undergoing outpatient Mohs micrographic surgery. Midazolam offers the benefits of amnesia, reduced alertness, and reduced blood pressure with no clinically significant adverse effects.

Multiple squamous cell carcinomas in the setting of psoriasis treated with etanercept: a report of four cases and review of the literature.

BACKGROUND: Psoriasis is a common, chronic, hyperproliferative disease of the skin characterized by overexpression of type 1 cytokines, including tumor necrosis factor α. There is concern that antitumor necrosis factor agents such as etanercept may increase the incidence of cutaneous malignancies; however, the data are conflicting. Our objective was to further understand the characteristics and association of squamous cell carcinoma (SCC) development in patients with psoriasis who used etanercept. METHODS: Four patients with psoriasis were identified as having SCCs in the setting of etanercept. The histories of these patients were reviewed retrospectively. RESULTS: All four patients had lifelong psoriasis. The mean time of SCC onset was 11 months after etanercept therapy was begun (range, 1-17 months), and the number of SCCs in each patient ranged from five to more than 50. CONCLUSIONS: Currently, reports are conflicting about the effect of etanercept on SCC development. We present the first case series of patients in whom SCC developed in the setting of etanercept therapy. More research is needed to better characterize the effects of etanercept on the development and behavior of SCC in patients with psoriasis.