Clinical Versus Histologic Margins for Cutaneous Squamous Cell Carcinoma: Comparing Outcomes for High-Risk Tumors Treated With Mohs Micrographic Surgery.

BACKGROUND: High-risk cutaneous squamous cell carcinoma (cSCC) is associated with poor clinical outcomes. Traditionally, preoperative clinical tumor size ≥2 cm, based on Brigham and Women's Hospital (BWH) staging criteria, is high risk. OBJECTIVE: To compare outcomes of cSCC treated with Mohs micrographic surgery (MMS) with a preoperative size ≥2 cm (clinically ≥2 cm) versus cSCC with preoperative size <2 cm and postoperative defect size ≥2 cm (histologically ≥2 cm). METHODS: Prospective data were collected from January 1, 2014, to December 31, 2020, on MMS cases for cSCC with a preoperative and/or postoperative size ≥2 cm. Clinical outcomes were followed until March 15, 2023. Data were analyzed using multivariate regression. RESULTS: Three hundred thirty cases of MMS for cSCC were included. Cutaneous squamous cell carcinoma clinically ≥2 cm occurred more frequently in elderly patients; cSCC histologically ≥2 cm were more commonly located in the H region, required wider surgical margins, and more MMS stages to achieve clearance. There were no significant differences in rates of recurrence and metastasis between the groups. CONCLUSION: These data suggest that postoperative (histologic) MMS defect size may allow for better risk stratification of high-risk cSCC and improved staging of cSCC.

Review of radiofrequency microneedling: history, devices and uses.

Radiofrequency microneedling (RFM) has recently become a popular choice for the treatment of various dermatologic conditions and rejuvenation. Many studies have sought to evaluate the efficacy of RFM. However, its role in the management of these conditions remains unclear. A comprehensive literature search including randomized controlled trials, cohort studies, and case series evaluating the efficacy of RFM in various skin conditions was performed. In this review, we discuss the history and mechanism of RFM, describe various device features, and discuss the use of RFM in various skin conditions and rejuvenation.

Permanent section margin concordance after Mohs micrographic surgery with immunohistochemistry for invasive melanoma and melanoma in situ: A retrospective dual-center analysis.

BACKGROUND: Mohs micrographic surgery (MMS) for melanoma practices vary among dermatologic surgeons. The implementation of immunohistochemical staining in MMS for melanoma mitigates challenges associated with slide interpretation; however, the reliability of melanoma antigen recognized by T cells 1 (MART-1), the preferred immunostain for melanoma, has yet to be compared with permanent section pathology. OBJECTIVE: To assess concordance rates of MART-1 frozen sections and permanent section pathologic interpretation of melanoma treated with MMS. METHODS: A dual-center retrospective analysis was conducted to collect concordance and demographic data. Chi-square tests were performed for group comparisons of categorical variables. RESULTS: Of the 379 permanent sections sent, 367 were concordant with frozen section pathology for an overall concordance rate of 96.8%. Cases were stratified into indeterminately concordant and indisputably concordant. Twenty-two (6%) of cases were indeterminately concordant, whereas 345 (94.0%) of cases were indisputably concordant. LIMITATIONS: The concordance rate is derived from a comparison of adjacent tissue margins, an inevitable consequence of utilizing 2 techniques. CONCLUSION: To the author's knowledge, this study represents the largest investigation examining concordance rates of MART-1 frozen sections in Mohs for melanoma. High concordance disputes the ongoing need for additional permanent margins when using MART-1 in routine cases.

Engineering of appropriate pore size combined with sulfonic functionalization in a Zr-MOF with reo topology for the ultra-high removal of cationic malachite green dye from an aqueous medium.

A Zr-based metal-organic framework with reo topology, denoted as Reo-MOF-1, was fabricated through a solvothermal method capable of efficiently removing the cationic MG dye from an aqueous medium. The effect of pH solution, adsorbent content, adsorption isotherm, and kinetics on the MG capture was observed to determine the optimal conditions. Accordingly, the maximum adsorption capacity of MG over H+⊂Reo-MOF-1 reaches the value of 2532.1 mg g-1 at neutral pH, which is much greater than the published materials. Moreover, the results of the MG process on H+⊂Reo-MOF-1 fit with the Langmuir isotherm and pseudo second order kinetic model. Hence, MG removal is a chemical adsorption process. Remarkably, H+⊂Reo-MOF-1 can maintain the uptake for MG at about 94% over eight cycles. The MG adsorption mechanism is interpreted via the incorporated analyses and experiments. In detail, Fourier transform infrared spectroscopy (FT-IR), Raman spectroscopy, powder X-ray diffraction (PXRD), and thermogravimetric analysis (TGA-DSC) of MG⊂Reo-MOF-1 in comparison with H+⊂Reo-MOF-1 indicate that the electrostatic attraction and π-π stacking interaction are found via the interaction between the cationic MG ions and SO3 - moieties within MOF as well as the π electron clouds in the benzene ring of the adsorbent and adsorbate, resulting in significant improvement the MG adsorption uptake. These data prove that acidified Reo-MOF-1 possesses promising application as an effective absorbent of toxic dye in practical conditions.

Antibiotic Use and Surgical Site Infections in Immunocompromised Patients After Mohs Micrographic Surgery: A Single-Center Retrospective Study.

BACKGROUND: As Mohs micrographic surgery becomes more widely used in immunosuppressed patients, it is important to understand the risks in this unique population. OBJECTIVE: To determine whether immunosuppressed patients are at an increased risk for surgical site infection and evaluate the utility of postoperative antibiotics for the prevention of surgical site infection. MATERIALS AND METHODS: A single-center retrospective review of patients who underwent Mohs micrographic surgery between October 9, 2014, and August 20, 2021, was performed. RESULTS: Five thousand eight hundred eighty-six independent cases were identified. Factors associated with an increased incidence of antibiotic use included preoperative lesion size >40 mm (86.7%, n = 13; p < .01) and high-risk lesion location (46.4%, n = 1,268; p < .01). Patients were not more likely to be prescribed antibiotics if immunosuppressed (37.0%, n = 269 vs 34.2%, n = 1765; p = .14), and immunosuppression was not independently associated with antibiotic use on multivariate analysis (odds ratio 1.2, 95% confidence interval 1.0-1.5). Infection rates were similar between immunocompromised patients and immunocompetent patients (2.1%, n = 15 vs 1.6%, n = 80, respectively; p = .30). In immunosuppressed patients, antibiotic use did not decrease the likelihood of infection (3.0%, n = 8 vs 1.5%, n = 7; p = .19). CONCLUSION: There was no association between immunosuppression and surgical infection rate. Furthermore, postoperative antibiotics should not be indicated in these patients unless other high-risk criteria exist.

Enhancing the remarkable adsorption of Pb2+ in a series of sulfonic-functionalized Zr-based MOFs: a combined theoretical and experimental study for elucidating the adsorption mechanism.

A series of Zr-based metal-organic frameworks was prepared via the solvothermal route using sulfonic-rich linkers for the efficient capture of Pb2+ ions from aqueous medium. The factors affecting adsorption such as the solution pH, adsorbent dosage, contact time, adsorption isotherms, and mechanism were studied. Consequently, the maximum adsorption capacity of Pb2+ on the acidified VNU-23 was determined to be 617.3 mg g-1, which is much higher than that of previously reported adsorbents and MOF materials. Furthermore, the adsorption isotherms and kinetics of the Pb2+ ion are in good accordance with the Langmuir and pseudo-second-order kinetic model, suggesting that the uptake of Pb2+ is a chemisorption process. The reusability experiments demonstrated the facile recovery of the H+⊂VNU-23 material through immersion in an HNO3 solution (pH = 3), where its Pb2+ adsorption efficiency still remained at about 90% of the initial uptake over seven cycles. Remarkably, the adsorption mechanism was elucidated through a combined theoretical and experimental investigation. Accordingly, the Fourier transform infrared spectroscopy (FT-IR), Raman spectroscopy, scanning electron microscopy connected to energy-dispersive X-ray mapping (SEM-EDX-mapping), and X-ray photoelectron spectroscopy (XPS) analysis of the Pb⊂VNU-23 sample and comparison with H+⊂VNU-23 confirmed that the electrostatic interaction occurs via the interaction between the SO3- moieties in the framework and the Pb2+ ion, leading to the formation of a Pb-O bond. In addition, the density functional theory (DFT) calculations showed the effective affinity of the MOF adsorbent toward the Pb2+ ion via the strong driving force mentioned in the experimental studies. Thus, these findings illustrate that H+⊂VNU-23 can be employed as a potential adsorbent to eliminate Pb2+ ions from wastewater.

A confinement of N-heterocyclic molecules in a metal-organic framework for enhancing significant proton conductivity.

A series of N-heterocyclic⊂VNU-23 materials have been prepared via the impregnation procedure of N-heterocyclic molecules into VNU-23. Their structural characterizations, PXRD, FT-IR, Raman, TGA, 1H-NMR, SEM-EDX, and EA, confirmed that N-heterocyclic molecules presented within the pores of parent VNU-23, leading to a remarkable enhancement in proton conductivity. Accordingly, the composite with the highest loading of imidazole, Im13.5⊂VNU-23, displays a maximum proton conductivity value of 1.58 × 10-2 S cm-1 (85% RH and 70 °C), which is ∼4476-fold higher than H+⊂VNU-23 under the same conditions. Remarkably, the proton conductivity of Im13.5⊂VNU-23 exceeds the values at 85% RH for several of the reported high-performing MOF materials. Furthermore, Im13.5⊂VNU-23 can retain a stable proton conductivity for more than 96 h, as evidenced by FT-IR and PXRD analyses. These results prove that this hybrid material possesses potential applications as a commercial proton exchange membrane fuel cell.

Complications associated with infraorbital filler injection.

Soft tissue augmentation with injectable fillers is increasingly being performed, and providers must be prepared to understand and treat complications. Periorbital skin presents unique challenges due to its thin nature, easily evident pigmentary and textural irregularities, and anatomical considerations including vasculature and subcutaneous layers. The most common complications of infraorbital filler include ecchymosis, malar edema, blue-gray hue, and contour irregularities. Uncommon complications include infection and biofilm formation, skin necrosis, and blindness. This purpose of this review is to highlight the infraorbital anatomy, complications of filler injection in this region, and techniques to avoid these complications.

Specific complications associated with non-surgical rhinoplasty.

Non-surgical rhinoplasty is becoming an increasingly common procedure to alter the appearance and cosmesis of the nose. Although rare, complications with this procedure do exist, some of which can be devastating. Major complications include infection, vascular compromise, skin necrosis, and blindness. Here we discuss the nasal anatomy, complications associated with non-surgical rhinoplasty, and techniques to prevent these complications.

Patterns of antimicrobial resistance in intensive care unit patients: a study in Vietnam.

BACKGROUND: Antimicrobial resistance has emerged as a major concern in developing countries. The present study sought to define the pattern of antimicrobial resistance in ICU patients with ventilator-associated pneumonia. METHODS: Between November 2014 and September 2015, we enrolled 220 patients (average age ~ 71 yr) who were admitted to ICU in a major tertiary hospital in Ho Chi Minh City, Vietnam. Data concerning demographic characteristics and clinical history were collected from each patient. The Bauer-Kirby disk diffusion method was used to detect the antimicrobial susceptibility. RESULTS: Antimicrobial resistance was commonly found in ceftriaxone (88%), ceftazidime (80%), ciprofloxacin (77%), cefepime (75%), levofloxacin (72%). Overall, the rate of antimicrobial resistance to any drug was 93% (n = 153/164), with the majority (87%) being resistant to at least 2 drugs. The three commonly isolated microorganisms were Acinetobacter (n = 75), Klebsiella (n = 39), and Pseudomonas aeruginosa (n = 29). Acinetobacter baumannii were virtually resistant to ceftazidime, ceftriaxone, piperacilin, imipenem, meropenem, ertapenem, ciprofloxacin and levofloxacin. High rates (>70%) of ceftriaxone and ceftazidime-resistant Klebsiella were also observed. CONCLUSION: These data indicated that critically ill patients on ventilator in Vietnam were at disturbingly high risk of antimicrobial resistance. The data also imply that these Acinetobacter, Klebsiella, and Pseudomonas aeruginosa and multidrug resistance pose serious therapeutic problems in ICU patients. A concerted and systematic effort is required to rapidly identify high risk patients and to reduce the burden of antimicrobial resistance in developing countries.

The Worsening Profile of Alcoholic Hepatitis in the United States.

BACKGROUND: Alcoholic hepatitis (AH) is a major cause of liver-related hospitalization. The profile, treatment patterns, and outcomes of subjects admitted for AH in routine clinical practice are unknown. Also, it is not known whether these are changing over time. This study is thus aimed to identify temporal trends in hospitalization rates, clinical characteristics, treatment patterns, and outcomes of subjects admitted for AH in a routine clinical setting. METHODS: A retrospective analysis of adults admitted for AH from 2000 to 2011 was performed using an anonymized EMR database of patient-level data from 169 U.S. medical centers. RESULTS: (i) EPIDEMIOLOGY: The proportion of baby boomers admitted for AH increased from 2000 to 2011 (26 to 31%, p < 0.0001). (ii) CLINICAL: The median Model for End-Stage Liver Disease (MELD) score increased over time from 12 to 14 (p = 0.0014) driven mainly by increased international normalized ratio (1.2 to 1.4, p < 0.0001). The median Charlson Comorbidity Index increased from 0 to 1 (p < 0.0001) with increased diabetes, chronic obstructive pulmonary disease, and heart disease. (iii) COMPLICATIONS: The following increased from 2001 to 2011: Gastrointestinal bleed-7 to 10% (p = 0.03); hepatic encephalopathy-7 to 13% (p < 0.0001); hepatorenal syndrome-1.8 to 2.8% (p = 0.0003); sepsis-0 to 6% (p < 0.0001); and pancreatitis-11 to 16% (p = 0.0061). (iv) Treatment patterns and mortality: Eight to 9% of subjects received steroids while pentoxifylline use increased to 2.2%. In those with MELD ≥ 22, mortality remained between 19 and 20% and only steroids modestly improved survival in this subset. CONCLUSIONS: Severe AH continues to have a high mortality. The severity and comorbidities and complications associated with AH have worsened. Drug therapy remains suboptimal.

Palisaded Neutrophilic Granulomatous Dermatitis in a Child with Juvenile Idiopathic Arthritis on Etanercept.

Palisaded neutrophilic granulomatous dermatitis (PNGD) is a rare neutrophilic dermatosis that may be associated with significant morbidity because of associated pruritus and pain. It is typically seen in adults with collagen vascular diseases, but may be associated with medications as well. PNGD is rarely reported in children. We describe a girl with polyarticular juvenile idiopathic arthritis who developed PNGD after administration of etanercept and demonstrated rapid and significant improvement upon treatment with topical triamcinolone 0.1% ointment.

"EB, or Not EB?" Neonatal Desquamative Impetigo in a Degloving Pattern.

We present the case of a 7-day-old boy with significant, rapidly spreading blistering and desquamation in a "degloving" pattern on the hands that mimicked epidermolysis bullosa but was ultimately diagnosed as bullous impetigo caused by a clinically aggressive strain of Staphylococcus aureus. Bullous impetigo is a desquamating condition caused by local release of S. aureus exfoliative toxin A and is more commonly seen in children. This case highlights the fragility of newborn skin and reviews the major diagnoses that should be considered in an infant with significant blistering.

The "Heart Sign": An Early Indicator of Dose-Dependent Doxycycline-Induced Phototoxicity.

Oral doxycycline is an antibiotic commonly used for the treatment of inflammatory acne in adolescents. Dose-dependent phototoxicity, unrelated to dose duration, is a well-known complication of its use. We present three adolescents who developed bilateral phototoxic rashes on the dorsal thenar spaces of their hands while taking doxycycline for their acne. Identification of the "heart sign" rash as a specific doxycycline-related phototoxic reaction should alert clinicians to the need for prompt intervention, including sun protection counseling and a possible change in antibiotics, in the uniquely vulnerable adolescent population. Early recognition may allow patients to avoid future, more widespread phototoxic drug reactions.

Imaging Pediatric Vascular Lesions.

Vascular anomalies are commonly encountered in pediatric and dermatology practices. Most of these lesions are benign and easy to diagnose based on history and clinical exam alone. However, in some cases the diagnosis may not be clear. This may be of particular concern given that vascular anomalies may occasionally be associated with an underlying syndrome, congenital disease, or serious, life-threatening condition. Defining the type of vascular lesion early and correctly is particularly important to determine the optimal approach to management and treatment of each patient. The care of pediatric patients often requires collaboration from a multitude of specialties including pediatrics, dermatology, plastic surgery, radiology, ophthalmology, and neurology. Although early characterization of vascular lesions is important, consensus guidelines regarding the evaluation and imaging of vascular anomalies does not exist to date. Here, the authors provide an overview of pediatric vascular lesions, current classification systems for characterizing these lesions, the various imaging modalities available, and recommendations for appropriate imaging evaluation.