MMS hotspots: a cross-sectional comparison of U.S. counties with and without Mohs micrographic surgery.

Healthcare access greatly impacts skin cancer diagnosis and mortality rates. Recognition of current disparities in Mohs micrographic surgery (MMS) access can assist future policy and clinical decisions to correct them. For the years 2014-2018, the CPT codes for MMS (17,311 and 17,313) were counted on a per county level across the United States per the Medicare Centers for Medicare & Medicaid Services (CMS) Medicare Prescriber Database. Any county with 0 MMS CPT codes recorded were classified as "without MMS cases." MMS "hotspots" were identified as counties that possessed a high average number of MMS cases compared to the national average, while also being surrounded by counties that possessed a low average number of MMS cases compared to the national average. Three thousand eighty-four counties in the United States were analyzed; 785 (25%) counties were designated as "with MMS cases" and 2301 (75%) "without MMS cases." There were no significant differences in age, ethnicity distribution, or cost per enrollee between the two designations. 74% of counties with MMS cases were considered urban, while only 25% of those without cases were urban (p < 0.01). The median household income was markedly higher in counties with MMS cases ($71,428 vs. $58,913, p < 0.01). With respect to education, more individuals in counties with MMS cases possessed their General Education Development (GED) (89% vs. 86%, p < 0.01) or a college degree (30% vs. 19%, p < 0.01). Forty-nine counties were considered MMS "hotspots." The density of MMS procedures varies greatly based on geography, maintaining the urban-rural disparity matched by the distribution of MMS surgeons. Additionally, there remains a wide income and educational gap between counties with and without MMS. Identifying MMS hotspots may facilitate further investigation into potential surgical access disparities.

Cardiovascular Adaptations of Space Travel: A Systematic Review.

INTRODUCTION: Space travel imposes significant gravitational and radiation stress on both cellular and systemic physiology, resulting in myriad cardiovascular changes that have not been fully characterized. METHODS: We conducted a systematic review of the cellular and clinical adaptations of the cardiovascular system after exposure to real or simulated space travel in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed and Cochrane databases were searched in June 2021 for all peer-reviewed articles published since 1950 related to the following search terms entered in separate pairs: "cardiology and space" and "cardiology and astronaut." Only cellular and clinical studies in English concerning the investigation of cardiology and space were included. RESULTS: Eighteen studies were identified, comprising 14 clinical and 4 cellular investigations. On the genetic level, pluripotent stem cells in humans and cardiomyocytes in mice displayed increased beat irregularity, with clinical studies revealing a persistent increase in heart rate after space travel. Further cardiovascular adaptations included a higher frequency of orthostatic tachycardia but no evidence of orthostatic hypotension, after return to sea level. Hemoglobin concentration was also consistently decreased after return to Earth. No consistent change in systolic or diastolic blood pressure or any clinically significant arrhythmias were observed during or after space travel. CONCLUSION: Changes in oxygen carrying capacity, blood pressure, and post-flight orthostatic tachycardia may serve as reasons to further screen for pre-existing anemic and hypotensive conditions among astronauts.

Is There a Role for Radiofrequency Devices in Hair?

Background: Radiofrequency (RF) devices are being increasingly used for cosmetic dermatology applications. Recent studies have reported an apparent dualistic nature of RF devices for hair, causing either removal or growth depending on the modality of RF. Materials and Methods: PubMed/MEDLINE and Web of Science searches were conducted in July 2022 according to PRISMA guidelines for studies discussing RF technology in hair applications (n = 19). Results: The majority of studies describe the utility of RF devices in removal of unwanted hair (n = 15). Bipolar RF has been used in combination with intense pulsed light for effective long-term removal of body and facial hair. The chromophore-independent method of energy delivery in RF makes it a viable add-on therapy for treating lighter colored hair and darker Fitzpatrick skin types. Monopolar RF is used for eyelash removal in patients with trichiasis. In contrast, fractional RF has been used to stimulate hair growth in patients with alopecia areata and androgenetic alopecia. Conclusions: Preliminary evidence supports the use of bipolar and monopolar RF devices for hair removal, while fractional RF appears to be an emerging technology for hair growth. Additional studies are needed to investigate the efficacy, mechanisms, and parameters of radiofrequency devices for various hair applications.

Current state of machine learning for non-melanoma skin cancer.

BACKGROUND: Machine learning (ML) has been increasingly utilized for skin cancer screening, primarily of melanomas but also of non-melanoma skin cancers (NMSC). OBJECTIVE: This study presents the first quantitative review of the success of these techniques in NMSC screening. METHODS: A primary literature search was conducted using PubMed, MEDLINE, and arXiv, capturing all articles involving ML techniques and NMSC screening. RESULTS: 52 articles were included for quantitative analysis, resulting in a mean sensitivity of 89.2% (n = 52, 95% confidence interval (CI) 87.0-91.3) and a mean specificity of 81.1% (n = 44, 95% CI 74.5-87.8) for ML algorithms in the diagnosis of NMSC. Studies were further grouped by skin cancer type, algorithm type, diagnostic gold standard, data set source, and data set size. CONCLUSION: There is insufficient evidence to conclude that an ML algorithm is superior at NMSC screening than a trained dermatologist utilizing dermoscopy for either BCC or SCC. Given that the studies included in this review were performed in silico, further study in the form of randomized clinical trials are needed to further elucidate the role of NMSC screening algorithms in dermatology.

Carcinoid Heart Disease: Pathophysiology, Pathology, Clinical Manifestations, and Management.

Carcinoid heart disease (CHD) is a rare and potentially lethal manifestation of an advanced carcinoid (neuroendocrine) tumor. The pathophysiology of CHD is related to vasoactive substances secreted by the tumor, of which serotonin is most prominent in the pathophysiology of CHD. Serotonin stimulates fibroblast growth and fibrogenesis, which can lead to cardiac valvular fibrosis. CHD primarily affects right heart valves, causing tricuspid and pulmonic regurgitation and less frequently stenosis of these valves. Left heart valves are usually spared because vasoactive substances such as serotonin are enzymatically inactivated in the lung vasculature. The pathology of CHD is characterized by plaque-like deposition of fibrous tissue on valvular cusps, leaflets, papillary muscles, chordae, and ventricular walls. Symptomatic CHD usually presents between 50 and 70 years of age, initially as dyspnea and fatigue. Echocardiography is the mainstay of imaging and demonstrates thickened right heart valves with limited mobility and regurgitation. Treatment focuses on control of the underlying carcinoid syndrome, targeting subsequent valvular heart disease and managing consequent heart failure. Surgical valve replacement and catheter-directed valve procedures may be effective for selected patients with CHD.

Identification and Management of Intermediate Risk Patients in the Chest Pain Unit.

OBJECTIVE: We examined low risk (LR) patients admitted to our chest pain unit (CPU) with negative cardiac injury markers, normal electrocardiogram, and clinical stability. We hypothesized that there is a sub-group of intermediate risk (IR) patients within the larger LR population. METHODS: Criteria for IR were the aforementioned 3 indicators of LR and ≥1 of the following: (1) known coronary artery disease (CAD), (2) men ≥45 yo, women ≥55 yo, and (3) ≥3 cardiac risk factors. We compared patient characteristics, use of pre-discharge testing (PDT), and major adverse cardiac events (MACE). RESULTS: IR patients numbered 371, whereas LR patients totaled 70. IR patients were older (61 vs 46 years), more had known CAD (28 vs. 0%), had a higher median number of risk factors (2 vs. 1) and were less likely to be women (49 vs. 81%), all P < 0.0001. IR patients received a greater median number of tests compared with LR patients (1 vs. 0, P < 0.0001). CONCLUSIONS: Among the IR group, 16 patients (4%) had a cardiac event at the index CPU visit, 2 (0.5%) experienced MACE at 30-day follow-up, and 2 (0.5%) had MACE at 6 months follow-up. No LR patients had MACE at any point in the study. Thus, the majority of CPU patients are IR, have more risk factors than LR group, and are more likely to receive PDT. IR patients were managed safely in a CPU, while maintaining low rates of MACE post-discharge.

Fulminant Myocarditis: Epidemiology, Pathogenesis, Diagnosis, and Management.

Fulminant myocarditis (FM) is a rare, distinct form of myocarditis that has been difficult to classify. Since 1991, the definition of FM has evolved, and it is currently considered an acute illness with hemodynamic derangement and arrhythmias due to a severe inflammatory process requiring support of cardiac pump function and/or urgent management of serious arrhythmias. Diagnosis is aided through use of biomarkers and cardiac imaging, but endocardial biopsy remains the gold standard. Recent evidence has revealed that patients with FM are significantly more likely to die or require heart transplantation than those with the nonfulminant form, refuting previous studies proposing a paradoxically low mortality in patients with FM. Acute hemodynamic derangement is managed by intensive contemporary pharmacologic and interventional approaches, whereas the role of immunosuppressive therapy has not been clarified. Early recognition and aggressive management are essential for favorable outcomes. In conclusion, FM is an inflammatory process requiring intensive support, and it causes a higher morbidity and mortality than acute nonfulminant myocarditis.

Role of and Recent Evidence for Antiplatelet Therapy in Prevention of Cardiovascular Disease in Diabetes.

PURPOSE OF REVIEW: When treating patients with diabetes mellitus (DM), the benefits of antiplatelet therapy in preventing cardiovascular disease must be weighed against an increased risk of bleeding. Recent trials have sought to determine both the optimal anti-platelet regimen for patients with DM, and who specifically requires medication among the DM population. This paper will review recent trials and evidence recommending the use of antiplatelet therapy in the prevention of cardiovascular disease in patients with diabetes. RECENT FINDINGS: Seven notable trials assessed the effectiveness of antiplatelet therapy in the DM population. The ASCEND trial concluded 100 mg aspirin/day reduced rates of serious vascular events (OR 0.88, p < 0.01) but also increased rates of major bleeding events (OR 1.29, p < 0.01). The DAPT study revealed a longer dual antiplatelet regimen (30 months vs. 18 months) after coronary stent placement was more effective in reducing rates of stent thrombosis (0.5% vs. 1.1%, p = 0.06) and rates of myocardial infarction (3.5% vs. 4.8%, p = 0.06). DECLARE DIABETES showed that adding cilostazol to dual antiplatelet therapy after a coronary stent procedure reduced rates of in-stent and in-segment late loss and increased rates of revascularization (p < 0.04). In PEGASUS-TIMI, daily ticagrelor demonstrated reduced rates of major adverse cardiovascular and cerebrovascular events (OR 0.84, p < 0.04). The DAVID trial compared daily picotamide with daily aspirin therapy, finding reduced mortality rates in the picotamide group (OR 0.55, p < 0.05). Lastly, ACUITY found bivalirudin monotherapy resulted in lower rates of major bleeding events when compared to a glycoprotein IIb/IIa inhibitor and heparin or bivalirudin combination regimen (p < 0.01). Dual antiplatelet therapy guidelines still typically revolve around aspirin, but an increasing number of studies have demonstrated other drugs that may have a role in preventing atherosclerotic cardiovascular disease while decreasing the risk of major bleeding. Overall, it is wise to weigh the cardiovascular risk of a DM patient before prescribing antiplatelet medication. More research is necessary to determine a universal drug or combination of drugs that is safe and effective for DM patients.