Anticipated Versus Unanticipated Incomplete Mohs Micrographic Surgery for Keratinocyte Carcinomas: Impact on Treatment Delays and Final Margin Status.

BACKGROUND: Mohs micrographic surgery may be discontinued with positive margins as an anticipated strategy for multidisciplinary care or as an unanticipated occurrence. Management of primary tumors has not been compared after anticipated versus unanticipated incomplete Mohs micrographic surgery (iMMS). OBJECTIVE: To compare rates and timing of adjuvant surgery after iMMS and final margin status when iMMS is anticipated versus unanticipated. Secondary outcomes were preoperative and intraoperative clinicopathologic factors associated with iMMS. METHODS: Cases of iMMS of keratinocyte carcinomas at a tertiary academic center between 2005 and 2022 were classified as anticipated (preoperative assembly of multidisciplinary teams) or unanticipated (ad hoc management of positive margins). Rate, timing, and final margin status of adjuvant surgery was compared between anticipated and unanticipated iMMS cohorts using χ2/Fisher exact test for categorical variables and t-test for continuous variables. RESULTS: Of 127 iMMS cases, 51.2% (65/127) were anticipated. Anticipated iMMS cases were more likely to undergo additional resection (98.5% vs 72.6%, p < .001), with fewer delays (3.9 vs 13.2 days, p < .001) and higher rates of final margin clearance (84.6% vs 59.7%, p < .001). CONCLUSION: When iMMS is anticipated as part of multidisciplinary care, patients are more likely to undergo additional resection, with fewer delays to next surgery and higher final margin clearance rates.

Individual Article: Over-the-Counter Moisturizers Significantly Improve Skin Hydration in Adults With Eczema/Atopy-Prone Skin.

BACKGROUND: Many adults suffer from dry, itchy skin, particularly those with eczema-prone skin. This study evaluated the effects of two over-the-counter (OTC) moisturizing products on skin hydration, transepidermal water loss (TEWL), ceramide levels, and patient experience. METHODS: Single-center, randomized, double-blind, split-body study evaluating the effectiveness of an Eczema Soothing Moisturizer (ESM) versus an Itch Relief Moisturizing Lotion (IRML) applied twice daily for 4 weeks in healthy adults with self-perceived persistent mild-to-moderate eczema-prone skin. Assessments included corneometer for skin hydration, evaporimeter for TEWL, tape stripping to measure ceramide NS and AS levels on the skin of the arm and leg, and a self-assessed participant-reported outcome questionnaire. RESULTS: A total of 30 adults completed the study. Both products significantly increased hydration, but the effect of ESM was greater than IRML (P=0.001), and both significantly decreased TEWL. At week 4, there were increases in NS and AS ceramides at both the legs and arms for both products (P<0.05 vs BL). Individually, ceramide content was significantly improved for ESM in the leg and for IRML in the arm at week 4 (P<0.05 vs BL). Participant photos show ESM was beneficial across a range of skin phototypes. Both products resulted in favorable perceptions from study participants. CONCLUSIONS: These moisturizers improved skin hydration, skin barrier, ceramide levels in the skin, and were well-perceived by the participants. This suggests that both products are beneficial for patients with eczema and eczema-prone skin. However, the hydrating effect of ESM was significantly greater than IRML. J Drugs Dermatol. 2023;22:10(Suppl 2):s16-20.

Evoking natural thermal perceptions using a thin-film thermoelectric device with high cooling power density and speed.

Multimodal sensory feedback from upper-limb prostheses can increase their function and usability. Here we show that intuitive thermal perceptions during cold-object grasping with a prosthesis can be restored in a phantom hand through targeted nerve stimulation via a wearable thin-film thermoelectric device with high cooling power density and speed. We found that specific regions of the residual limb, when thermally stimulated, elicited thermal sensations in the phantom hand that remained stable beyond 48 weeks. We also found stimulation sites that selectively elicited sensations of temperature, touch or both, depending on whether the stimulation was thermal or mechanical. In closed-loop functional tasks involving the identification of cold objects by amputees and by non-amputee participants, and compared with traditional bulk thermoelectric devices, the wearable thin-film device reliably elicited cooling sensations that were up to 8 times faster and up to 3 times greater in intensity while using half the energy and 1/600th the mass of active thermoelectric material. Wearable thin-film thermoelectric devices may allow for the non-invasive restoration of thermal perceptions during touch.

Evolving teledermatology policy and reimbursement landscape in the United States.

Background: Policymakers and payers are reevaluating the temporary telehealth flexibilities granted during the COVID-19 public health emergency, which will shape future teledermatology utilization. Objective: To summarize the recently expanded telehealth flexibilities in the United States, projected changes, and corresponding implications for dermatologists. Methods: Narrative review of the literature, United States policies and regulations, and white paper reports. Results: Key telehealth flexibilities included expansion of payment parity, relaxation of originating site requirements, loosening of state licensure requirements, and HIPAA (Health Insurance Portability and Accountability Act of 1996) enforcement discretion. These changes enabled widespread accessibility and adoption of teledermatology, which enhanced high-quality and cost-effective dermatologic care. Most waivers will end 151 days following the end of the public health emergency declaration. Notably, asynchronous telehealth was not included in the reimbursement expansion. Limitations: Only policies and regulations through December 2022 are included. Conclusion: It will be important for the field of dermatology to stay abreast of the upcoming changes in telemedicine policies and reimbursement, to demonstrate teledermatology's value through evidence-based studies and to advocate for enduring policies that will promote the accessibility of teledermatology for patients.

A framework for de-identification of free-text data in electronic medical records enabling secondary use.

Clinical free-text data represent a vast, untapped source of rich information. If more accessible for research it would supplement information captured in structured fields. Data need to be de-identified prior to being reused for research. However, a lack of transparency with existing de-identification software tools makes it difficult for data custodians to assess potential risks associated with the release of de-identified clinical free-text data. This case study describes the development of a framework for releasing de-identified clinical free-text data in two local health districts in NSW, Australia. A sample of clinical documents (n = 14 768 965), including progress notes, nursing and medical assessments and discharge summaries, were used for development. An algorithm was designed to identify and mask patient names without damaging data utility. For each note, the algorithm output the (i) note length before and after de-identification, (ii) the number of patient names and (iii) the number of common words. These outputs were used to iteratively refine the algorithm performance. This was followed by manual review of a random subset of records by a health information manager. Notes that were not correctly de-identified were fixed, and performance was reassessed until resolution. All notes in this sample were suitably de-identified using this method. Developing a transparent method for de-identifying clinical free-text data enables informed-decision making by data custodians and the safe re-use of clinical free-text data for research and public benefit.

Giant pigmented apocrine hidrocystoma of the scalp.

Hidrocystomas are benign cysts of sweat duct epithelium that can present as single or multiple lesions, with or without pigmentation. The size is typically 1-3mm in diameter. Although hidrocystomas commonly occur in most parts of the head and neck region, occurrence on the scalp is rare. Herein, we present a 29-year-old woman with a giant pigmented apocrine hidrocystoma of the scalp, which, to our knowledge, represents the largest of its kind reported to date.

Clinical effectiveness and cost-effectiveness of teledermatology: Where are we now, and what are the barriers to adoption?

There has been rapid growth in teledermatology over the past decade, and teledermatology services are increasingly being used to support patient care across a variety of care settings. Teledermatology has the potential to increase access to high-quality dermatologic care while maintaining clinical efficacy and cost-effectiveness. Recent expansions in telemedicine reimbursement from the Centers for Medicare & Medicaid Services (CMS) ensure that teledermatology will play an increasingly prominent role in patient care. Therefore, it is important that dermatologists be well informed of both the promises of teledermatology and the potential practice challenges a continuously evolving mode of care delivery brings. In this article, we will review the evidence on the clinical and cost-effectiveness of teledermatology and we will discuss system-level and practice-level barriers to successful teledermatology implementation as well as potential implications for dermatologists.

Texture Discrimination using a Soft Biomimetic Finger for Prosthetic Applications.

Soft robotic fingers have shown great potential for use in prostheses due to their inherent compliant, light, and dexterous nature. Recent advancements in sensor technology for soft robotic systems showcase their ability to perceive and respond to static cues. However, most of the soft fingers for use in prosthetic applications are not equipped with sensors which have the ability to perceive texture like humans can. In this work, we present a dexterous, soft, biomimetic solution which is capable of discrimination of textures. We fabricated a soft finger with two individually controllable degrees of freedom with a tactile sensor embedded at the fingertip. The output of the tac- tile sensor, as texture plates were palpated, was converted into spikes, mimicking the behavior of a biological mechanoreceptor. We explored the spatial properties of the textures captured in the form of spiking patterns by generating spatial event plots and analyzing the similarity between spike trains generated for each texture. Unique features representative of the different textures were then extracted from the spikes and input to a classifier. The textures were successfully classified with an accuracy of 94% when palpating at a rate of 42 mm/s. This work demonstrates the potential of providing amputees with a soft finger with sensing capabilities, which could potentially help discriminate between different objects and surfaces during activities of daily living (ADL) through palpation.

An Adaptive Socket Attaches onto Residual Limb Using Smart Polymers for Upper Limb Prosthesis.

A major challenge for upper limb amputees is discomfort due to improper socket fit on the residual limb during daily use of their prosthesis. Our work introduces the implementation of soft robotic actuators into a prosthetic socket. The soft actuators are a type of electrically-powered actuator. The actuator is driven through changes in internal temperature causing actuation due to vapor pressure, which results in high and reliable force outputs. A regression fit was generated to model how the smart polymer's temperature relates to force output, and the model was cross-validated based on training data collected from each actuator. A proportional integral (PI) controller regulated the force exerted by the actuators based off of tactile and temperature feedback. Results showed that a socket system can be integrated with smart polymers and sensors, and demonstrated the ability to control two actuators and reach desired forces from set temperatures.

Designing an Adaptive Prosthetic Socket Controller Using H-Infinity Loop Shaping Synthesis.

Amputees often find wearing a prosthetic limb for a long period of time uncomfortable. Prosthetic sockets that adjust the socket's fit automatically, or adaptive sockets, would encourage amputees to wear their prosthesis more frequently. In this work, we simulate the control system design of a Multiple-Input, Multiple-Output (MIMO) adaptive socket using principles of optimal control and robust control. A data-driven model of the socket-limb interface is first obtained by applying regression to open-loop recordings of the socket interacting with the limb during a simulated grasping task. A MIMO controller is then designed to maintain a desired uniform socket fit. An $H_{\infty}$ controller, obtained from loop shaping synthesis using the Glover-McFarlane method, is shown to perform comparably to a Linear Quadratic Gaussian (LQG) controller while maintaining robustness to uncertainties in the socket-limb interface model. This work then outlines a potential procedure on how to develop the control system for a real adaptive prosthetic socket with multiple sensors and actuators.

Incidence of AIDS-Related Kaposi Sarcoma in All 50 United States From 2000 to 2014.

BACKGROUND: Although declining rates of incident AIDS-related Kaposi sarcoma (KS) have been reported, KS incidence rates have noted race/ethnic, age, and geographic diversity. We performed a comprehensive assessment of recent secular trends in AIDS-related KS incidence in the United States. METHODS: We identified incident KS diagnosed in men aged 20-54 years (who comprise most AIDS-related KS in the United States) using the US Cancer Statistics registry data. Joinpoint analysis assessed for trends in age-adjusted incidence rates between 2000 and 2014 calculating average annual percentage changes (AAPCs) with 95% confidence intervals. Heat maps were generated to compare age-adjusted HIV incidence rates with KS incidence rates. RESULTS: Age-adjusted KS incidence rates nationwide decreased from 1.44/100,000 to 0.95/100,000 between 2000 and 2014. Observed rate changes varied across subgroups; eg, there were significant decreases in 30-44 years (AAPC = -5.4%), particularly in Whites and Blacks, significant increases among 20-29 years (AAPC = 2.7), primarily in Blacks, and stable rates among 45-54 years (AAPC = -0.03). In Southern United States, the incidence rates among Blacks did not significantly change. The states with highest average age-adjusted rates over the study period were Georgia (2.71/100,000), New York (2.16/100,000), California (2.02/100,000), Florida (1.90/100,000), and Texas (1.39/100,000), with significantly decreasing trends over time, except Georgia where rates increased (AAPC = 1.8). CONCLUSIONS: Although KS incidence rates have decreased nationally, age, racial, and geographic disparities persist, including increasing risk among younger Black men and particularly elevated rates in some southern states and urban areas. Further research is needed to address racial and geographic AIDS-related KS disparities.