ABSTRACT
Understanding patient non-adherence to prescribed antibiotics can inform clinical practices, patient counseling, and antibiotic efficacy study design in dermatology. The primary objective was to determine the rate of and reasons for antibiotic non-adherence in the dermatologic surgery setting. The secondary objective was to test the applicability of previously studied survey questions for antibiotic non-adherence screening in the dermatologic surgery setting. Five academic outpatient dermatologic surgery centers across the United States conducted one multicenter prospective cohort study. Dermatologic surgery patients ≥ 18 years of age who were prescribed an antibiotic were included as part of this study. 15.2% (42/276) of patients did not adhere to their antibiotic regimen after dermatologic surgery. Most common reasons for incomplete antibiotic courses included forgotten antibiotics (42.9%,18/42) and side effects (28.6%, 12/42). Previously evaluated questions to identify and predict non-adherence had modest performance in the dermatologic surgery setting (Area under the curve of 0.669 [95% CI (0.583-0.754)]). Antibiotic non-adherence after skin surgery is prevalent and commonly due to reasons that physicians can address with patients.
Subject(s)
Anti-Bacterial Agents , Medication Adherence , Humans , Anti-Bacterial Agents/therapeutic use , Anti-Bacterial Agents/administration & dosage , Prospective Studies , Female , Middle Aged , Male , Medication Adherence/statistics & numerical data , Aged , Dermatologic Surgical Procedures/adverse effects , Surgical Wound Infection/prevention & control , Surgical Wound Infection/epidemiology , Adult , United States , Surveys and Questionnaires/statistics & numerical dataABSTRACT
OBJECTIVE: To describe local recurrence rates and patient-reported outcomes when Mohs micrographic surgery with cytokeratin-7 immunostains (MMS-CK7) is included in the interdisciplinary management of extramammary Paget's disease (EMPD) METHODS: A retrospective study was conducted of EMPD treated with MMS-CK7 as part of an interdisciplinary team at an academic medical center between 2009 and 2016. Local recurrence rates and patient-reported outcomes were determined by record review and patient surveys. RESULTS: Twenty tumors in 19 patients were treated using MMS-CK7. After MMS-CK7 defined clear microscopic margins, 75% (15/20) of tumors underwent excision or reconstruction by a surgical colleague. Internal malignancy screening was performed by multiple specialties in 17 patients, with 1 associated malignancy of prostate cancer detected. No local recurrence was detected with a mean follow-up of 75.2 months. Most patients were satisfied with appearance (18/19, 95%) and function (16/19, 84%) after surgery. CONCLUSION: Interdisciplinary teams that include MMS-CK7 can treat EMPD with low local recurrence rates, high patient satisfaction, and thorough internal malignancy screening.
Subject(s)
Mohs Surgery , Paget Disease, Extramammary , Frozen Sections , Humans , Keratin-7 , Male , Margins of Excision , Neoplasm Recurrence, Local/pathology , Paget Disease, Extramammary/diagnosis , Paget Disease, Extramammary/surgery , Retrospective StudiesABSTRACT
BACKGROUND: Prospective trials have not compared the local recurrence rates of different excision techniques for cutaneous melanomas on the head and neck. OBJECTIVE: To determine local recurrence rates of cutaneous head and neck melanoma after wide local excision (WLE), Mohs micrographic surgery (MMS), or staged excision. METHODS: A systematic review of PubMed, EMBASE, and Web of Science identified all English case series, cohort studies, and randomized controlled trials that reported local recurrence rates after surgery for cutaneous head and neck melanoma. A meta-analysis utilizing a random effects model calculated weighted local recurrence rates and confidence intervals (CI) for each surgical technique and for subgroups of MMS and staged excision. RESULTS: Among 100 manuscripts with 13,998 head and neck cutaneous melanomas, 51.0% (7138) of melanomas were treated by WLE, 34.5% (4826) by MMS, and 14.5% (2034) by staged excision. Local recurrence rates were lowest for MMS (0.61%; 95% CI, 0.1%-1.4%), followed by staged excision (1.8%; 95% CI, 1.0%-2.9%) and WLE (7.8%; 95% CI, 6.4%-9.3%). LIMITATIONS: Definitions of local recurrence varied. Surgical techniques included varying proportions of invasive melanomas. Studies had heterogeneity. CONCLUSION: Systematic review and meta-analysis show lower local recurrence rates for cutaneous head and neck melanoma after treatment with MMS or staged excision compared to WLE.
Subject(s)
Melanoma , Skin Neoplasms , Humans , Melanoma/epidemiology , Melanoma/surgery , Mohs Surgery , Neoplasm Recurrence, Local/epidemiology , Prospective Studies , Retrospective Studies , Skin Neoplasms/epidemiology , Skin Neoplasms/surgery , Melanoma, Cutaneous MalignantABSTRACT
Atypical fibroxanthomas are rare, superficial dermal tumors. Most cases are benign and only locally destructive with a low rate of metastasis. Lesions are most commonly found on sun-exposed sites of elderly light-skinned patients and present as asymptomatic nodules with irregular borders; ulcerations and friability are other key characteristics. Pedunculated lesions, however, are rarely described in the literature. We present two cases of atypical fibroxanthoma manifesting as exophytic, pedunculated lesions on the face: one in a 74-year-old man and the other in an 82-year-old woman. These tumors are very effectively treated by excision with Mohs micrographic surgery.
Subject(s)
Facial Neoplasms/pathology , Neoplasms, Fibrous Tissue/pathology , Skin Neoplasms/pathology , Aged , Aged, 80 and over , Facial Neoplasms/surgery , Female , Humans , Male , Mohs Surgery , Neoplasms, Fibrous Tissue/surgery , Skin Neoplasms/surgeryABSTRACT
Lymphomatoid papulosis (LyP) is a chronic skin condition, characterized by recurrent eruptions of papules and nodules with or without central necrosis that spontaneously resolve. This condition was originally described by Macaulay in 1968 as a self-healing rhythmical paradoxical eruption that was clinically benign yet histologically malignant.1 Clinically, it is defined by papules that wax and wane, are generally less than 1cm in diameter, and heal spontaneously after 68 weeks with subsequent scarring.2
Subject(s)
Lymphomatoid Papulosis/diagnosis , Skin Neoplasms/diagnosis , T-Lymphocyte Subsets , Administration, Cutaneous , Adult , Clobetasol/administration & dosage , Clobetasol/therapeutic use , Diagnosis, Differential , Female , Humans , Leg , Lymphomatoid Papulosis/drug therapy , Lymphomatoid Papulosis/pathology , Skin Neoplasms/drug therapy , Skin Neoplasms/pathologyABSTRACT
BACKGROUND: The use of surgical video has great potential to enhance surgical education, but there exists limited information about how to effectively use surgical videos. We performed a systematic review of video technology in surgical training and provided evidence-based recommendations for its effective use. MATERIALS AND METHODS: A systematic review of literature on surgical video in residency education was conducted. All articles meeting inclusion criteria were evaluated for technical characteristics pertaining to video usage. Included studies were critically appraised using a quality-scoring system. Recommendations were provided for the effective implementation of video in surgical education based on associations with improved training outcomes. RESULTS: Twenty articles met inclusion criteria. In these studies, the source of video acquisition was primarily laparoscopy (40.0% of papers), and the main perspective of video was endoscopy (45.0%). Features of videos included supplementation with other educational tools (55.0%), schematic diagrams or images (50.0%), audio (40.0%), and narration (25.0%). Videos were primarily viewed preoperatively (60.0%) or postoperatively (50.0%). The intended viewer for videos was usually residents (70.0%) but also included attendings/faculty (30.0%). When compared with a nonvideo training group, video training was associated with improved resident knowledge (100%), improved operative performance (81.3%), and greater participant satisfaction (100%). CONCLUSIONS: Based on this review, we recommend that surgical training programs incorporate schematics and imaging into video, supplement video with other education tools, and utilize audio in video. For video review, we recommend that residents review video preoperatively and postoperatively for learning and that attendings review video postoperatively for assessment.
Subject(s)
Education, Medical, Graduate/methods , Specialties, Surgical/education , Video Recording , HumansABSTRACT
BACKGROUND: Multidisciplinary cleft care depends on follow-up at specified time points to monitor and address functional or aesthetic concerns that may arise during a child's development. However, loss to follow-up (LTFU) is common and can lead to missed opportunities for therapeutic and surgical intervention. This study explores clinical, demographic, and geographic determinants of LTFU in cleft care. METHODS: Medical records were retrospectively evaluated for 558 pediatric patients of a single mid-volume cleft team. The primary outcome was LTFU. Spatial dependency was evaluated using variograms. The probability of LTFU was assessed using a generalized linear geostatistical model within a Bayesian framework. Risk maps were plotted to identify vulnerable communities within our state at higher risk of LTFU. RESULTS: Younger age at last encounter was a strong predictor of LTFU (P < 0.0001), even when ignoring spatial dependency among observations. When accounting for spatial dependency, lower socioeconomic status [OR = 0.98; 95% CI = (0.97-0.99)] and cleft phenotype [OR = 0.55; 95% CI = (0.36, 0.81)] were significant predictors of LTFU. Distance from the cleft team and rural/urban designation were not statistically significant predictors. Cartographic representation of predicted probability of LTFU revealed vulnerable communities across our state, including in the immediate vicinity of our cleft center. CONCLUSIONS: Geostatistical methods are able to identify risk factors missed by traditional statistical analysis. Knowledge of vulnerable populations allow a cleft team to allocate more resources toward high-risk areas to rectify or prevent deficiencies in care.
ABSTRACT
Self-induced masticatory trauma is an unfortunate complication of a variety of neurologic disorders, including epileptic seizures, cerebral palsy, mental retardation, psychiatric disease, and brain trauma, in addition to other described etiologies. While single or occasional occurrences of tongue biting are relatively benign, recurrent self-injury can pose major issues and predispose a patient to chronic, severe complications. To prevent the complications associated with ongoing trauma to the tongue, steps must be taken to protect individuals from chronic self-injurious behavior. Often, these interventions cause significant morbidity to the patient, such as elective removal of the dentition or complications in gaining access to the oral cavity/airway associated with maxillomandibular fixation. In the neurologically impaired patient, immobilization of the jaws is frequently associated with higher rates of agitation, aspiration, or development of complicating infections of the gingival tissues. We report a case of self-induced masticatory trauma managed with the fabrication of a custom-fabricated oral appliance. This treatment modality successfully prevents the recurrence or incidence of self-induced masticatory trauma to the tongue. The benefits of this modality are that it allows access to the oral cavity, prevents immobilization of the jaws, has minimal to no morbidity, and is completely reversible.
ABSTRACT
BACKGROUND: Few data exist to guide surgical management and counseling about local recurrence after surgery of primary male genital melanoma. OBJECTIVE: To compile all available data on local recurrence rates after surgery of primary cutaneous melanoma of the penis and scrotum. MATERIALS AND METHODS: A systematic review of PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Excerpta Medica database (EMBASE), and Web of Science identified all surgically treated penile and scrotal melanomas that reported local recurrence status and follow-up time. RESULTS: One hundred twenty-seven melanomas from 74 manuscripts were included. Eighty-six percent of melanomas were located on the penis, and 14% were located on the scrotum. Average follow-up time was 35.7 months. Scrotal melanomas were predominantly treated with organ-sparing surgeries (16/18, 88.9%), whereas penile melanomas were treated more often with amputation (61/109, 56.0%). Overall, local recurrence rate was 15.7% (20/127). Local recurrence rates for penile cases were 18.8% (9/48) after organ-sparing surgery versus 13.1% (8/61) for amputative surgery. Local recurrence rates were 66.7% (4/6) after positive surgical margins versus 10.2% (5/49) after negative surgical margins. CONCLUSION: Local recurrence rates are high after both organ-sparing and amputative surgery of primary cutaneous melanoma of the penis and scrotum. There is a need to standardize reporting for this rare tumor, as more complete data are necessary to develop consensus guidelines for surgical management of male genital melanoma.
Subject(s)
Melanoma/surgery , Neoplasm Recurrence, Local/epidemiology , Penile Neoplasms/surgery , Scrotum , Skin Neoplasms/surgery , Humans , Male , Treatment Outcome , Melanoma, Cutaneous MalignantABSTRACT
OBJECTIVE: Our objective is to describe the process of adapting a conceptual framework into a practical toolkit for one cleft team. DESIGN: This is a single-arm implementation study in a single institution. SETTING: Implementation took place at a mid-sized multidisciplinary clinic for patients with cleft lip and/or palate (CL/P) from urban/suburban and rural areas across North Carolina and neighboring states. PARTICIPANTS: Eligible participants were patients with CL/P from English-speaking families. Sixty patients entered and finished the study. INTERVENTIONS: The implementation of a prospective data collection system based on the International Consortium for Health Outcomes Measurement (ICHOM) standard set of outcome measures for CL/P was accomplished in multiple stages. Patient- and clinician-reported forms and protocols for gathering data were created. Team members were trained and the system was tested; finally, the system was deployed. MAIN OUTCOME MEASURES: Success was appraised using the RE-AIM framework to assess reach, effectiveness, adoption, implementation, and maintenance. RESULTS: Ninety-eight percent of patients and all team members agreed to participate. Ninety-four percent of required data were captured. Adaptations to friction points were made; specifically, visible reminders were affixed to charts, primary clinicians were required to assume data entry responsibility, and e-mail reminders were instituted. Development cost was US$7707; average time cost per clinician was 21 min/wk. CONCLUSIONS: Conceptual frameworks for outcomes studies must be tailored to their environments; otherwise, they cannot be practically implemented and sustained. We present this process for a cleft team using the ICHOM standard set. The process may help other teams implement the standard set or other conceptual frameworks.
Subject(s)
Cleft Lip/therapy , Cleft Palate/therapy , Data Collection/standards , Outcome Assessment, Health Care/standards , Adolescent , Child , Child, Preschool , Female , Humans , Infant , Male , Prospective Studies , Young AdultSubject(s)
Dermatologists/psychology , Dermatology , Electronic Mail , Hospital Communication Systems , Physician Assistants/psychology , Work-Life Balance , Burnout, Professional/etiology , Burnout, Professional/psychology , Dermatology/organization & administration , Electronic Health Records , Electronic Mail/statistics & numerical data , HumansABSTRACT
In the implementation of American Society for Apheresis national guidelines, the decision for therapeutic plasma exchange may be confounded by a clinical presentation that fits both a Category I and IV designation. We report the case of a 45-year-old female who presented with concern for a Category IV disorder, gemcitabine-induced thrombotic microangiopathy, and was ultimately diagnosed with a Category I disorder, idiopathic thrombotic thrombocytopenic purpura. This case highlights the importance of ruling out idiopathic TTP by a thorough evaluation for ADAMTS13 activity and inhibitor, even when an alternate thrombotic microangiopathy diagnosis may be likely.
Subject(s)
Deoxycytidine/analogs & derivatives , Purpura, Thrombotic Thrombocytopenic/diagnosis , Thrombotic Microangiopathies/diagnosis , ADAMTS13 Protein/immunology , ADAMTS13 Protein/metabolism , Deoxycytidine/adverse effects , Diagnosis, Differential , Female , Humans , Middle Aged , Plasma Exchange , Practice Guidelines as Topic , Thrombocytopenia/classification , Thrombocytopenia/diagnosis , Thrombocytopenia/therapy , Thrombotic Microangiopathies/chemically induced , GemcitabineABSTRACT
There are few reports of chemotherapy-induced eccrine squamous syringometaplasia in children. We report the first case of an infant developing this condition after treatment with busulfan, fludarabine, and antithymocyte globulin in preparation for bone marrow transplantation. Twenty-eight days after transplantation, the infant developed faintly erythematous papules and plaques on the bilateral axillae, inguinal folds, and sites of adhesives. Punch biopsy revealed eccrine glands with dyskeratotic cells and focal squamous metaplasia consistent with chemotherapy-induced eccrine squamous syringometaplasia.