Mohs Micrographic Surgery for Invasive Melanoma Allows for Tissue Preservation Compared With Wide Local Excision: A Retrospective Cohort Study.

BACKGROUND: While increasing evidence supports the safety and effectiveness of immunohistochemistry-assisted Mohs micrographic surgery (MMS) for superficially invasive melanoma, there is a paucity of the literature investigating its effect on final defect size. OBJECTIVE: To evaluate the tissue sparing effect of MMS for melanoma. MATERIALS AND METHODS: Three hundred and twenty-eight patients with early-stage (T1a/T1b) cutaneous melanomas treated with MMS from January 2008 to December 2018 were evaluated. Measured defect sizes after Mohs tumor extirpation were compared with anticipated defect size that would result from standard-margin wide local excision (WLE). Average actual versus anticipated defect areas were compared using a paired t-test (95% confidence intervals). RESULTS: The following groups demonstrated a significantly smaller defect area for MMS-treated tumors when compared with anticipated standard-margin WLE defect: All tumors combined (13.8 cm2 vs 10.4 cm2, p < .001), tumors requiring 1 stage (13.6 cm2 vs 10.1 cm2,p < .001), and tumors requiring 2 stages (13.2 cm2 vs 10.5 cm2, p = .004). The majority of patients (83.5%, n = 274) achieved clear margins with 1 stage. CONCLUSION: Immunohistochemistry-assisted MMS for early-stage invasive melanoma is associated with smaller final defect size and overall tissue sparing effect compared with standard WLE margins.

Bridging the gap in BASCULE syndrome: A retrospective case series of a recently described clinical entity.

BACKGROUND: Bier anemic spots, cyanosis with urticaria-like eruption (BASCULE) syndrome is a recently described entity with episodic urticarial lesions and white anemic halos on a background of erythrocyanosis, commonly affecting the lower extremities. Possible association with autonomic dysfunction remains poorly understood. Existing publications are limited, but the condition is suggested as highly underrecognized. OBJECTIVE: To further characterize clinical and epidemiologic data for BASCULE syndrome. METHODS: We performed an IRB-approved retrospective chart review on patients with BASCULE syndrome evaluated at Mayo Clinic from April 2021 to November 2022. RESULTS: A total of 17 patients were identified (13 female, 4 male). Median age of onset was 12 years (range 9-17). Lower extremities were involved in all patients (17). Most patients were symptomatic with pruritus (8) or burning pain (8); three were asymptomatic. Triggers were standing (11), hot showers or hot environments (7), or no clear trigger (4). Autonomic dysfunction was present in 10 patients. Treatment responses were observed from propranolol (3) and high-dose cetirizine (1). CONCLUSION: Novel epidemiologic data from 17 pediatric and young adult patients with BASCULE syndrome further supports an association with autonomic dysfunction and suggests a higher prevalence than previously acknowledged.

Evaluating Feasibility, Value and Characteristics of an Intergenerational Friendly Telephone Visit Program During the Covid-19 Pandemic.

OBJECTIVE: Volunteer organizations offer telephone outreach to older adults to relieve feelings of loneliness and to promote emotional well-being, though the feasibility, perceived value, and characteristics of the participant experience of these community interventions have not been well-studied. We examined these elements of an intergenerational college-based telephone call program during the Covid-19 pandemic. METHODS: Community-dwelling older adults and undergraduate volunteers engaged in eight, weekly, 30-minute, unscripted telephone conversations. Feasibility criteria included enrollment, retention, and attendance rates. A rapid qualitative analysis of program evaluation responses was used to extract themes related to participants' experiences of the intervention. RESULTS: Ten older adults (mean age [range] 74.53 [70-84] years, 88% women) and nine undergraduates were enrolled from February to August 2021, achieving recruitment targets and enrollment rates of 76.9% and 90%. Seven out of the 10 enrolled dyads completed the full series of eight telephone conversations and qualitative assessments over an average of 10.5 weeks. Most older adults who completed the call schedule valued the conversations as a source of social connection, noting the mutuality, respect, and broadened perspective that characterized their intergenerational relationships. Undergraduates described value in giving to others and in conversations that stimulated personal reflection and feelings of closeness. Undergraduates frequently described their experience as novel and broadening of their perspectives. CONCLUSION: Though study completion rate and participant experience varied across dyads, we found qualitative evidence of perceived value, active relationship-building and broadened perspectives among many older adults and undergraduates who completed an intergenerational telephone program.

Anatomic Site-Specific Complication Rates for Central Venous Catheter Insertions.

BACKGROUND: Central venous catheter (CVC) complication rates reflecting the application of modern insertion techniques to a clinically heterogeneous patient populations are needed to better understand procedural risk attributable to the 3 common anatomic insertion sites: internal jugular, subclavian, and femoral veins. We sought to define site-specific mechanical and duration-associated CVC complication rates across all hospital inpatients. METHODS: A retrospective chart review was conducted over 9 months at Georgetown University Hospital and Washington Hospital Center. Peripherally inserted central catheters and tunneled or fluoroscopically placed CVC's were excluded. Mechanical complications (retained guidewire, arterial injury, and pneumothorax) and duration-associated complications (deep vein thrombosis or pulmonary embolism, and central line-associated bloodstream infections) were identified. RESULTS: In all, 1179 CVC insertions in 801 adult patients were analyzed. Approximately 32% of patients had multiple lines placed. Of 1179 CVCs, 73 total complications were recorded, giving a total rate of one or more complications occurring per CVC of 5.9%. There was no statistically significant difference between site-specific complications. A total of 19 mechanical complications were documented, with a 1.5% complication rate of one or more mechanical complications occurring. A total of 54 delayed complications were documented, with a 4.4% complication rate of 1 or more delayed complications occurring. There were no statistically significant differences between anatomic sites for either total mechanical or total delayed complications. CONCLUSIONS: These results suggest that site-specific CVC complication rates may be less common than previously reported. These data further inform on the safety of modern CVC insertion techniques across all patient populations and clinical settings.

Treatment of morphea with hydroxychloroquine: A retrospective review of 84 patients at Mayo Clinic, 1996-2013.

BACKGROUND: Few studies support treating morphea (localized scleroderma) with hydroxychloroquine. OBJECTIVE: To assess the efficacy of hydroxychloroquine treatment of morphea. METHODS: We conducted a retrospective study of 84 patients who had morphea and were treated with hydroxychloroquine monotherapy for at least 6 months at our institution from 1996 through 2013. The median times to initial and maximal responses were assessed. RESULTS: Of the 84 patients (median age at diagnosis, 29.5 years), 65 (77.4%) were female, 36 (42.9%) had a complete response to hydroxychloroquine, 32 (38.1%) had a partial response greater than 50%, 10 (11.9%) had a partial response less than or equal to 50%, and 6 (7.1%) had no response. The median time to initial response was 4 months, and the median time to maximal response was 12 months. Ten patients (11.9%) experienced adverse effects from hydroxychloroquine; the most common adverse effect was nausea (6 patients). LIMITATIONS: Retrospective study. CONCLUSIONS: Hydroxychloroquine is a valuable treatment for morphea because of its high response rate and low rate of adverse effects; however, prospective studies are needed to determine its true efficacy.

Trichotillomania (hair pulling disorder): Clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations.

Trichotillomania (hair pulling disorder) is a fairly common but underreported disorder characterized by recurrent episodes of pulling hair from different parts of the body. Currently classified in Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-5) under the heading of the "Obsessive-compulsive spectrum and related disorders." The estimated prevalence data suggest that 0.5-2% of the general population suffers from this disorder. Stress and anxiety are directly correlated to the production of trichotillomania symptoms. The psychosocial aspects of trichotillomania are greatly underestimated, but recent literature suggests an increased interest in this neglected area. Although no FDA approved medications are available for the treatment of trichotillomania, a variety of medications including N-acetylcysteine have shown benefit in case reports. Combined liaison clinics, with an interdisciplinary approach, are highly advisable in the treatment of these cases.

Concordance Between Bone Pathology and Bone Culture for the Diagnosis of Osteomyelitis in the Presence of Charcot Neuro-Osteoarthropathy.

The diagnosis of osteomyelitis (OM) is a challenging but critical pathology to uncover in patients with concomitant Charcot neuro-osteoarthropathy (CN). The reference standard to diagnose OM is bone biopsy for histopathologic and microbiologic examination. The presence of CN, however, can have a negative effect on the accuracy of either method to identify OM. The aim of the present study was to examine the concordance between bone pathology and bone cultures in the presence of CN in the diagnosis of OM. A total of 286 patients with diabetes mellitus (DM) and CN were identified retrospectively, with 48 patients identified with OM. OM was confirmed by radiographs, magnetic resonance imaging, erythrocyte sedimentation rate, and C-reactive protein, positive probe-to-bone test results, and intraoperative inspection. Seventy matched pairs of bone pathology and cultures with complete data were compared and analyzed. Statistical analysis included concordance, positive predictive value, negative predictive value, sensitivity, specificity, and kappa coefficient. Concordance between bone pathology and bone culture was 41.4%, with agreement in 29 of 70 paired specimens. The diagnostic test accuracy of histopathologic examination to diagnose OM in CN bone in our study was 51.4%. The diagnostic test accuracy of microbiologic examination to diagnose OM in CN bone was 50%. The positive predictive value was 72.2%. The negative predictive value was 44.1%. The sensitivity was 57.8%. The specificity was 60.0%. The kappa coefficient was 0.165. The reference standard method of histopathologic and microbiologic examination of bone specimens has little concordance and can lead to inaccurate or inconclusive information. The low sensitivity and specificity demonstrated in the present study does not support the use of the current reference standard method of bone biopsy for histologic and microbiologic diagnosis of OM when CN is present. Thus, a diagnosis of OM in patients with CN should only be considered in the presence of strong clinical, laboratory, and imaging correlates.

Minimally Invasive Surgery Survey: A Survey of Surgical Team Members' Perceptions for Successful Minimally Invasive Surgery.

STUDY OBJECTIVE: To develop a valid and reliable survey to measure surgical team members' perceptions regarding their institution's requirements for successful minimally invasive surgery (MIS). DESIGN: Questionnaire development and validation study (Canadian Task Force classification II-2). SETTING: Three hospital types: rural, urban/academic, and community/academic. PARTICIPANTS: Minimally invasive staff (team members). INTERVENTION: Development and validation of a minimally invasive surgery survey (MISS). MEASUREMENT AND MAIN RESULTS: Using the Safety Attitudes questionnaire as a guide, we developed questions assessing study participants' attitudes regarding the requirements for successful MIS. The questions were closed-ended and responses based on a 5-point Likert scale. The large pool of questions was then given to 4 focus groups made up of 3 to 6 individuals. Each focus group consisted of individuals from a specific profession (e.g., surgeons, anesthesiologists, nurses, and surgical technicians). Questions were revised based on focus group recommendations, resulting in a final 52-question set. The question set was then distributed to MIS team members. Individuals were included if they had participated in >10 MIS cases and worked in the MIS setting in the past 3 months. Participants in the trial population were asked to repeat the questionnaire 4 weeks later to evaluate internal consistency. Participants' demographics, including age, gender, specialty, profession, and years of experience, were captured in the questionnaire. Factor analysis with varimax rotation was performed to determine domains (questions evaluating similar themes). For internal consistency and reliability, domains were tested using interitem correlations and Cronbach's α. Cronbach's α > .6 was considered internally consistent. Kendall's correlation coefficient τ closer to 1 and with p < .05 was considered significant for the test-retest reliability. Two hundred fifty participants answered the initial question set. Of those, 53 were eliminated because they did not meet inclusion criteria or failed to answer all questions, leaving 197 participants. Most participants were women (68% vs 32%), and 42% were between the ages 30 and 39 years. Factor analysis identified 6 domains: collaboration, error reporting, job proficiency/efficiency, problem-solving, job satisfaction, and situational awareness. Interitem correlations testing for redundancy for each domain ranged from .2 to .7, suggesting similar themed questions while avoiding redundancy. Cronbach's α, testing internal consistency, was .87. Sixty-two participants from the original cohort repeated the question set at 4 weeks. Forty-three were analyzed for test-retest reliability after excluding those who did not meet inclusion criteria. The final questions showed high test-retest reliability (τ = .3-.7, p < .05). The final questionnaire was made up of 29 questions from the original 52 question set. CONCLUSION: The MISS is a reliable and valid tool that can be used to measure how surgical team members conceptualize the requirements for successful MIS. The MISS revealed that participants identified 6 important domains of a successful workenvironment: collaboration, error reporting, job proficiency/efficiency, problem-solving, job satisfaction, and situational awareness. The questionnaire can be used to understand and align various surgical team members' goals and expectations and may help improve quality of care in the MIS setting.

The history of Botulinum toxin: from poison to beauty.

Botulinum toxin, also called the "miracle toxin," is a neurotoxin produced by the bacteria Clostridium botulinum. It is known to block nerve signals that contract muscles resulting in a temporary paralysis of the muscles. Toxins type A and B have been extensively studied and utilized in the realm of beauty and cosmetology. Initially, the toxin gained popularity as a disease-causing "poison". It was only later that it found its way to becoming a must have in modern aesthetic practice. Today, this wonder toxin has proven to be an apt and convenient option in the field of anti-aging medicine.

Comparison of Completion Rates for SF-36 Compared With SF-12 Quality of Life Surveys at a Tertiary Urban Wound Center.

Patient-reported outcome measures derived from quality of life instruments are an important tool in monitoring disease progression and treatment response. Although a number of validated instruments are available, the Short Form-36 (SF-36) quality of life survey is the most widely used. It is imperative that the patients answer all the questions in this instrument for appropriate analysis and interpretation. It has been hypothesized that fewer questions (i.e., the Short Form-12 [SF-12]), will result in greater survey completion rates. The present study was a randomized prospective study comparing the completion rates for the SF-36 and SF-12 quality of life surveys. Patients presenting with a chronic wound were asked to complete the SF-36 or SF-12 survey. After an a priori power analysis was performed, the completion rates, patterns of skipped questions, and demographic information were analyzed using t tests for continuous variables or Fisher's exact test for categorical variables and both multivariate linear regression and logistic regression. A total of 59 subjects (30 completed the SF-12 and 29 completed the SF-36) participated in the present study. The SF-12 group had an 80% (24 of 30) completion rate compared with a 55% (16 of 29) completion rate for the SF-36 group (p < .05). However, the length of the survey did not affect the completion rate nor was a statistically detectable pattern of skipped questions found. College graduates were more likely to complete both surveys compared with high school graduates (p < .07). Although it is unclear why, our study results indicate that the SF-12 yields a higher total survey completion rate. However, completion appears independent of the shorter survey length.

The impact of gross anatomy laboratory on first year medical students' interest in a surgical career.

This study sought to determine the impact of gross anatomy laboratory (GA) on first year medical students' (M1) interest in a surgical career. Secondary objectives included identifying other influences in M1s' career decision making. This prospective study included surveys before and after GA. All M1s enrolled in GA were invited to participate. Sixty students completed both the pre- and post-test surveys. A 5-point Likert-type scale surveyed participants' interests, specific personality traits, experience during the course of GA, and likelihood of pursuing a surgical career. Statistical analysis included Wilcoxon Signed Rank Test and (Polychotomous) Ordinal Logistic Regression Model. Students' desire to work with their hands increased (50 vs. 33.3%) and enjoyment working with instruments and tools similarly increased (50 vs. 41.7%). Likelihood of pursuing a surgical career after gross anatomy increased in 31.7% of students, decreased in 16.7%, and was unchanged in 51.7%. Over 75% of students with a prior interest in surgery and 21% of those who previously felt neutral agreed that they were likely to pursue a career in surgery at the conclusion of the laboratory. Students with a surgeon family member were 0.1976 times as likely to exhibit a positive change in interest (P values 0.024). Gross anatomy may influence up to a third of the class to consider a surgical career, especially those with a prior interest in surgery and those previously feeling ambivalent. Students with a surgeon family member became less likely to enter a surgical career after gross anatomy. Clin. Anat. 29:691-695, 2016. © 2016 Wiley Periodicals, Inc.

Risk factors associated with tumor upstaging in melanomas treated with Mohs micrographic surgery with melanocytic immunohistochemistry.

Background: Mohs micrographic surgery with melanocytic immunohistochemistry (MMS-I) is increasingly utilized for special site melanoma treatment. Yet, frequency and risk factors associated with upstaging of all-stage cutaneous melanomas treated with MMS-I remain undefined. Objective: Determine upstaging frequency and factors associated with tumor upstaging for all-stage melanomas treated with MMS-I. Methods: In this retrospective, single-center case series, all cases of invasive and in situ melanoma treated with MMS-I between 2008 and 2018 were reviewed. Patient and tumor characteristics were recorded and compared between tumors that were and were not upstaged from their initial T stage. Results: Of the 962 melanoma MMS-I cases identified, 44 (4.6%) were upstaged, including 5.6% of in situ and 2.5% of invasive tumors. Risk factors for upstaging included lack of excisional intent at the time of initial biopsy (P < .01), nonlentigo maligna subtype (P = .03), female sex (P = .02), and initial in situ diagnosis (P = .03). Nonstatistically significant characteristics evaluated included patient age (P = .97), initial Breslow depth (P = .18), and biopsy type (P = .24). Limitations: Retrospective study design. Conclusions: All-stage cutaneous melanomas treated with MMS-I are associated with low upstaging rates. Tumor upstaging is associated with lack of excisional intent, female sex, and in situ tumors.

Results of Patch Testing to Botanicals: Review of the Mayo Clinic Experience Over 2 Decades (1997-2017).

Background: Botanicals are increasingly incorporated into skincare products. Although allergic contact dermatitis due to botanicals is recognized, data describing the prevalence of positive patch tests to botanicals are sparse. Objective: To report the Mayo Clinic experience of patch testing to selected botanical products in the standard, extended standard, fragrance, and plant series. Methods: IRB-approved retrospective study of the Mayo Clinic experience with patch testing to botanicals from 1997 to 2017. Results: In total, 12,169 people were patch tested to botanicals in the standard, extended standard, fragrance, and plant series; 4032 were men and 8137 were women. The mean age of the population tested was 54 (standard deviation 17.7) years. Almost 11% (1320/12,169) of the patch-tested population exhibited positive reactions to at least 1 botanical agent. Myroxylon pereirae resin 25% was the most common positive allergen in the series. Patients who had positive reactions to at least 1 botanical agent were more (19.8%) likely to have a positive reaction to at least 1 additional botanical than those patients who did not have any positive tests. Most patients presented with generalized involvement (334) or involvement of the hands (284) or face (232). Conclusion: Physicians should be aware of the high prevalence of allergic contact dermatitis and patch test positivity associated with botanical products.

Decoding information about cognitive health from the brainwaves of sleep.

Sleep electroencephalogram (EEG) signals likely encode brain health information that may identify individuals at high risk for age-related brain diseases. Here, we evaluate the correlation of a previously proposed brain age biomarker, the "brain age index" (BAI), with cognitive test scores and use machine learning to develop and validate a series of new sleep EEG-based indices, termed "sleep cognitive indices" (SCIs), that are directly optimized to correlate with specific cognitive scores. Three overarching cognitive processes were examined: total, fluid (a measure of cognitive processes involved in reasoning-based problem solving and susceptible to aging and neuropathology), and crystallized cognition (a measure of cognitive processes involved in applying acquired knowledge toward problem-solving). We show that SCI decoded information about total cognition (Pearson's r = 0.37) and fluid cognition (Pearson's r = 0.56), while BAI correlated only with crystallized cognition (Pearson's r = - 0.25). Overall, these sleep EEG-derived biomarkers may provide accessible and clinically meaningful indicators of neurocognitive health.

Association of BRAF V600E Status of Incident Melanoma and Risk for a Second Primary Malignancy: A Population-Based Study.

Mutations of the BRAF oncogene occur in both melanomas and several other cancers. Our objective was to determine if mutant BRAF V600E expression in a population-based cohort of patients with melanoma was associated with the development of a second primary malignancy of any type. Using the resources of the Rochester Epidemiology Project, we retrospectively identified 380 patients aged 18 to 60 years who were diagnosed with an incident melanoma from 1970 through 2009. We reviewed individual medical records to identify second primary malignancies. We evaluated mutant BRAF V600E expression from available melanoma tissue specimens and assessed its association with the development of a second primary malignancy. BRAF V600E expression in melanomas is associated with an increased risk for basal cell carcinoma (BCC).

Resident Training in Transitioning Youth With Epilepsy Into Adult Care.

OBJECTIVE: To appraise the current training of Neurology (N), Pediatric (P), and Med-Peds (MP) residents at MedStar Georgetown University Hospital (MGUH) in providing care to patients with epilepsy who are transitioning from pediatric to adult care. METHODS: Through an online questionnaire, we surveyed Neurology, Pediatric, and Med-Peds residents to assess their knowledge, confidence, and experience at transitioning youth with epilepsy to adult-oriented health care. RESULTS: N, P, and MP residents generally rated their knowledge and confidence at providing transition care to youth with epilepsy to be poor; however, P and MP residents rated higher in limited measures of knowledge and experience. CONCLUSION: Our appraisal of resident training in transitions care for youth with epilepsy has highlighted training elements in our institution that require attention for both adult and pediatric providers, leading to the formulation of an educational intervention that will promote experiential and multimodal approaches in this area.