The Incidence of Pouch Neoplasia Following Ileal Pouch-Anal Anastomosis in Patients With Inflammatory Bowel Disease.

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is the standard restorative procedure following proctocolectomy in patients with inflammatory bowel disease (IBD) who require colectomy. However, removal of the diseased colon does not eliminate the risk of pouch neoplasia. We aimed to assess the incidence of pouch neoplasia in IBD patients following IPAA. METHODS: All patients at a large tertiary center with International Classification of Diseases-Ninth Revision/International Classification of Diseases-Tenth Revision codes for IBD who underwent IPAA and had subsequent pouchoscopy were identified using a clinical notes search from January 1981 to February 2020. Relevant demographic, clinical, endoscopic, and histologic data were abstracted. RESULTS: In total, 1319 patients were included (43.9% women). Most had ulcerative colitis (95.2%). Out of 1319 patients, 10 (0.8%) developed neoplasia following IPAA. Neoplasia of the pouch was seen in 4 cases with neoplasia of the cuff or rectum seen in 5 cases. One patient had neoplasia of the prepouch, pouch, and cuff. Types of neoplasia included low-grade dysplasia (n = 7), high-grade dysplasia (n = 1), colorectal cancer (n = 1), and mucosa-associated lymphoid tissue lymphoma (n = 1). Presence of extensive colitis, primary sclerosing cholangitis, backwash ileitis, and rectal dysplasia at the time of IPAA were significantly associated with increased risk of pouch neoplasia. CONCLUSIONS: The incidence of pouch neoplasia in IBD patients who have undergone IPAA is relatively low. Extensive colitis, primary sclerosing cholangitis, and backwash ileitis prior to IPAA and rectal dysplasia at the time of IPAA raise the risk of pouch neoplasia significantly. A limited surveillance program might be appropriate for patients with IPAA even with a history of colorectal neoplasia.

The incidence of pouch neoplasia in inflammatory bowel disease patients who have undergone ileal pouch­anal anastomosis (IPAA) is low. Extensive colitis, primary sclerosing cholangitis, and backwash ileitis prior to IPAA as well as rectal dysplasia at time of IPAA raise the risk of pouch neoplasia significantly.

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.

An update on long-term outcomes of pediatric follicular mucinosis over a 20-year period: a retrospective cohort study.

BACKGROUND: Follicular mucinosis (FM) is a rare disease characterized by mucin accumulation in the follicular unit. FM's etiology is still widely debated since its first description in 1957. Follicular mucinosis is usually reported to be benign in children, although reports of malignant transformation, most commonly mycosis fungoides, exist. The present project aims to demonstrate that children with a diagnosis of follicular mucinosis have positive long-term outcomes and do not develop mycosis fungoides. MATERIALS AND METHODS: This is a retrospective cohort study where patients with a diagnosis of follicular mucinosis ages 22 years and below were identified. Data surrounding the patient's diagnosis of FM, differential diagnosis, treatments, and long-term outcomes were collected. Patients who were lost to follow-up were contacted by phone for an update on the status of their skin and overall health. RESULTS: Out of 14 patients with follow-up information, none developed subsequent mycosis fungoides or other hematologic malignancies. CONCLUSION: Pediatric patients with follicular mucinosis will likely present with limited disease and not experience malignant transformation.

Impact of anticoagulation and antiplatelet therapy on dialysis catheter fibrin sheath formation.

PURPOSE Fibrin sheaths are a significant cause of dialysis catheter dysfunction. This study aimed to determine the role of anticoagulation, antiplatelet medications, and other factors in delaying fibrin sheath formation. METHODS An institutional review board-approved retrospective review of all patients treated for tunneled dialysis catheter fibrin sheaths from January 2014 to January 2020 was undertaken. All catheters were symmetric tipped, 14.5 F in diameter, and placed via the internal jugular vein. Seventy patients with venographically confirmed fibrin sheaths that developed after de novo catheter placement were identified. Recurrent fibrin sheaths were excluded. The impact of anticoagulation and antiplatelet therapy, as well as statin therapy, catheter side (right or left), hematocrit, platelet count, prothrombin time (PT), and international normalized ratio (INR), on the time to fibrin sheath formation was determined. RESULTS Patients on anticoagulation had a longer median catheter implantation time of 109.2 days (interquartile range (IQR): 29.3-178.5 days) compared to 80.7 days (IQR: 28.0-168.6 days) among patients not on anticoagulation. Catheter dwell time among patients taking antiplatelet therapy was 86.0 days (IQR: 31.5-160.7 days) versus 74.4 days (IQR: 27.5-202.4 days) for patients not on antiplatelet medication. Patients taking statins versus those not taking statins had median catheter dwell times of 97.5 days (IQR: 27.5-138.5 days) and 62.4 days (IQR: 29.9-259.6 days), respectively. Time to fibrin sheath formation was not significantly associated with hematocrit (P =.16), platelet count (0.12), PT (P =.51), or INR (P =.74). CONCLUSION Anticoagulation has no significant benefit in delaying sheath formation in patients with tunneled dialysis catheters. Hematologic and coagulation parameters at the time of catheter placement were also not associated with catheter dwell time.

Perioperative Bleeding Associated With Ibrutinib in Dermatologic Surgery: A Case-Control Study.

BACKGROUND: Ibrutinib, an irreversible Bruton tyrosine kinase inhibitor, has been associated with an increased risk of bleeding. There is a paucity of data on the risk of bleeding in patients on ibrutinib undergoing dermatologic surgery. OBJECTIVE: To determine the frequency of bleeding complications associated with ibrutinib in patients undergoing dermatologic surgery. MATERIALS AND METHODS: A retrospective, single-center, case-control study of patients on ibrutinib undergoing skin surgery between January 2013 and March 2020 compared with sex, disease, and age-matched control patients undergoing cutaneous surgeries. RESULTS: A total of 75 surgeries performed on 37 case patients and 116 surgeries performed on 64 control patients were included. Ibrutinib was associated with a statistically significant increased rate of bleeding events (6/75 [8%] vs 1/116 [0.8%], p -value = .02). Compared with ibrutinib patients who did not have a bleeding event, those on ibrutinib who suffered bleeding were all men, older (mean age 82.7 vs 73.0, p -value= .01), and had lower mean platelet counts (104.0 vs 150.5 K/µL, p -value = .03). CONCLUSION: Ibrutinib may be associated with increased risk of bleeding in patients with hematologic malignancies, particularly older men with lower platelet levels and on multiple anticoagulants. Transient discontinuation of ibrutinib should be considered for dermatologic surgeries.

Is There a Smoking Gun for Nicotine? A Review of the Role of Nicotine in Dermatologic Surgery.

BACKGROUND: Dermatologic surgeons are faced with a dilemma when counseling actively smoking patients who require dermatologic surgery: recommend total cessation of all nicotine that is associated with extremely high rates of cessation failure or recommend nicotine replacement therapy (NRT). OBJECTIVE: To determine the safety of NRT in dermatologic surgery. MATERIALS AND METHODS: PubMed was queried: [(nicotine OR electronic cigarettes) AND (flap OR wound healing)]. RESULTS: Smoking tobacco is detrimental to wound healing, supported by ample evidence (1A). Perioperative smoking cessation reduces risk (1B). Basic science demonstrates both a benefit and detriment of nicotine depending on the factor studied (2A). Human studies suggest no detrimental effect of nicotine on perioperative complications (1B). Nicotine may be detrimental to flaps, but evidence is limited to basic science (2A). CONCLUSION: Dermatologists should consider recommending nicotine replacement for smokers in the perioperative period. Evidence is lacking to determine safety in flaps. It is presumed based on animal studies that nicotine has a negative effect on flaps; however, it is likely less than tobacco. Weighing the risk of cessation failure without nicotine replacement versus nicotine replacement after flap is challenging. Electronic cigarettes should be discouraged as a means of NRT.

Technical success and safety of peripherally inserted central catheters in the great saphenous and anterior accessory great saphenous veins.

BACKGROUND: Peripherally inserted central catheters (PICC) are occasionally placed in the great saphenous vein (GSV) and anterior accessory great saphenous vein (AAGSV) in patients with inadequate upper extremity veins or contraindications to upper extremity placement. Outcomes on the placement of PICCs in these veins are limited. OBJECTIVES: This study aimed to determine technical success and safety of GSV/AAGSV PICCs. MATERIALS AND METHODS: This is a retrospective study that reviewed all GSV/AAGSV PICC placements between January 2011 and December 2019. A total of 29 PICC placements procedures were identified. The electronic medical record was queried for demographic, procedural, and complication data. Technical success was defined by whether the vein could be accessed and a PICC could be placed. Catheter-associated infections, dislodgement or migration, malfunction, and PICC-associated thrombosis were recorded. RESULTS: Technical success of placement was 100%. Twenty-one (72%) catheters were placed in the GSV in the mid to upper thigh and eight (28%) were placed in the AAGSV. The median PICC dwell time was 13 days with a range of 3-155 days. PICC-associated complications occurred after 11 (37.9%) placements. Line associated infection was the most common complication (17.2%). CONCLUSION: Due to a high complication rate, GSV/AAGSV PICC placement should be considered only when upper extremity or cervical PICC placement is not feasible or contraindicated.

Blue-black hyperpigmentation on the extremities.

In some cases, diagnosis entails less "what is it?" and more "what caused it?"