How Should the Recovery Process Be Shared Between Patients and Clinicians?

Illness and injury often entail lasting health and social consequences beyond the acute event. During the immediate and long-term recovery period, consequences of illness or injury can often be mitigated and addressed. As patients and their clinicians discuss care decisions, whether for initial or ongoing management of illness or injury, they must consider patients' personal goals of recovery alongside possible clinical outcomes to choose the best path forward. Understanding the recovery process and patients' and clinicians' decision making requires clarifying the concept of recovery and its significance. This article will describe how shared decision making can support the recovery process using a case example of brachial plexus injury.

Squamous Cell Carcinoma of the Hand: A Retrospective Study in Immunosuppressed and Immunocompetent Individuals.

BACKGROUND: Cutaneous squamous cell carcinoma (SCC) of the hand presents a treatment challenge because of the anatomical complexity of this location. Immunosuppressed patients are disproportionately affected by cutaneous SCC. Existing data on SCC of the hand are primarily presented in the orthopedic literature, and may thus be affected by referral bias. OBJECTIVE: Characterization of epidemiology and treatment outcomes for hand versus nonhand cutaneous SCC in immunosuppressed versus immunocompetent patients, across all clinical departments. MATERIALS AND METHODS: Single-institution retrospective cohort study of cutaneous SCC evaluated over 3 years and hand SCC over an additional 5 years. RESULTS: A cohort of 522 hand SCC cases (1,746 total SCC) was ascertained among 1,064 patients, of whom 175 were immunosuppressed. Occurrence on the hand was more common for SCC arising in immunosuppressed versus immunocompetent patients (38% vs 24% of cases respectively). Hand SCC cases demonstrated balanced laterality and comparable spectra of differentiation regardless of immunosuppression. No cases of hand SCC metastasis were observed over greater than 2 years' mean follow-up, and digital amputation was only required in approximately 1% of hand SCCs. CONCLUSION: In our cohort, assessment of hand SCC across all clinical departments suggests more favorable prognosis than reflected in the previous literature.

Atypical Fibroxanthoma: The Washington University Experience.

BACKGROUND: Atypical fibroxanthoma (AFX) is a rare dermal neoplasm typically occurring on sun-exposed skin in the elderly. As AFX remains a diagnosis of exclusion, updated characterization and treatment assessments are necessary to support informed diagnosis and management. OBJECTIVE: Characterization of contemporary AFX and surgical outcomes by Mohs micrographic surgery (MMS) and conventional local excision (LE). METHODS: Retrospective cohort analysis of all cases of AFX at our institution from January 2000 through July 2016. RESULTS: Among 75 cases with median age at diagnosis 73 years, most occurred on the head and neck (68) independent of age. Most treated cases (42) underwent MMS alone, with median tissue removal greater for LE (2.6 cm, 4.5 cm) than MMS (0.6 cm, 1.2 cm). Over a median 26 months of follow-up, 6 recurrences were observed among 50 cases, with metastases in 2 cases. Intent-to-treat recurrence rates were 3.4% for MMS and 25% for LE. One nonrecurrent and 2 recurrent cases received revised diagnoses after initial treatment, yielding a true recurrence rate of 8.5%. CONCLUSION: Despite diagnostic confounding by similar pathologies, surgical treatment of AFX remains effective. Tissue-sparing resection by MMS affords the potential for cosmetic and reconstructive advantage, without compromising recurrence compared with conventional excision.

Ethical considerations in the use of biopolymer sutures.

Biopolymer suture materials, namely gut and silk, represent under-recognized sources of potential ethical conflict in the informed consent of surgical patients. Objections to acceptance of such products may be made on both religious and secular grounds, and should not be discounted by assumption. Consistent with contemporary medical ethics, informed consent thus ought to include disclosure of use and source of these animal-derived products, as is the case with dressings and prostheses. Potential substitutes may be found in synthetic suture materials suitable for both absorbable and permanent placement, providing practical options to the conscientious physician.

Concurrent metastases of papillary thyroid carcinoma to the scalp and Meckel's cave.

We present the case of a 65-year-old man with severe headaches and unilateral facial weakness, seen in consultation by the dermatology service to rule out primary cutaneous melanoma after brain imaging identified an enlarging mass within the right trigeminal (Meckel's) cave. Examination revealed only a pair of erythematous papules on the scalp, for which biopsy demonstrated metastatic papillary thyroid carcinoma. Further evaluation and subsequent thyroidectomy confirmed the origin of widespread internal disease, followed by definitive excision of scalp lesions and multimodal management of systemic involvement. Whereas presentation of metastasis to the skin is highly variable, a low threshold for biopsy may allow for histological identification of internal disease not otherwise considered in the clinical differential.