Protective role of CXCR7 activation in neonatal hyperoxia-induced systemic vascular remodeling and cardiovascular dysfunction in juvenile rats.

Neonatal hyperoxia induces long-term systemic vascular stiffness and cardiovascular remodeling, but the mechanisms are unclear. Chemokine receptor 7 (CXCR7) represents a key regulator of vascular homeostasis and repair by modulating TGF-ß1 signaling. This study investigated whether pharmacological CXCR7 agonism prevents neonatal hyperoxia-induced systemic vascular stiffness and cardiac dysfunction in juvenile rats. Newborn Sprague Dawley rat pups assigned to room air or hyperoxia (85% oxygen), received CXCR7 agonist, TC14012 or placebo for 3 weeks. These rat pups were maintained in room air until 6 weeks when aortic pulse wave velocity doppler, cardiac echocardiography, aortic and left ventricular (LV) fibrosis were assessed. Neonatal hyperoxia induced systemic vascular stiffness and cardiac dysfunction in 6-week-old rats. This was associated with decreased aortic and LV CXCR7 expression. Early treatment with TC14012, partially protected against neonatal hyperoxia-induced systemic vascular stiffness and improved LV dysfunction and fibrosis in juvenile rats by decreasing TGF-ß1 expression. In vitro, hyperoxia-exposed human umbilical arterial endothelial cells and coronary artery endothelial cells had increased TGF-ß1 levels. However, treatment with TC14012 significantly reduced the TGF-ß1 levels. These results suggest that dysregulation of endothelial CXCR7 signaling may contribute to neonatal hyperoxia-induced systemic vascular stiffness and cardiac dysfunction.

Diagnosis and Management of Acral Pigmented Lesions.

BACKGROUND: Survival outcomes in acral lentiginous melanoma (ALM) are worse than for cutaneous melanoma. Diagnostic delays are believed to contribute to worse outcomes in ALM, including advanced-stage disease at initial presentation. Acral lentiginous melanoma, especially in its early stages, may be difficult to discern from benign pigmented acral lesions. OBJECTIVE: The purpose of this article is to provide a comprehensive review of the diagnosis and management of acral pigmented lesions. MATERIALS AND METHODS: A literature review was performed. The outcomes included were the clinical and dermoscopic features and the management frameworks and considerations for acquired and congenital melanocytic nevi, acral melanosis, nonmelanocytic pigmented lesions, and ALM. RESULTS: Original research studies were primarily included. The use of dermoscopy, such as the 3-step algorithm and blotch (irregular), ridge pattern (parallel), asymmetry of structures, asymmetry of colors, furrow pattern (parallel), fibrillar pattern (BRAAFF) checklist, increases the diagnostic accuracy of acral pigmented lesions with high specificity and sensitivity. Short-term digital dermoscopic surveillance can be used to manage acral lesions, and histopathology should be collected when there is a concern for ALM. CONCLUSION: The use of dermoscopy and an understanding of how to manage acral lesions may limit the number of biopsies performed on the acral skin, decrease the time to diagnosis, and facilitate early detection of ALM.

Direct Vision, Transfascial (DVT) Approach to Submuscular Reservoir Placement in Patients Undergoing Multicomponent Penile Implant Surgery Following Prior Pelvic Surgery or Radiation Therapy.

BACKGROUND: Submuscular reservoir placement has fulfilled a critical need for patients desiring multicomponent penile implants following pelvic surgery and radiation therapy. Passage of the reservoir through the inguinal canal into the submuscular space is often challenging and carries the risk of the reservoir being placed unknowingly outside of the targeted space. AIM: To evaluate the safety and accuracy of a direct vision, transfascial (DVT) approach to submuscular reservoir placement. METHODS: We retrospectively reviewed outcomes for consecutive patients undergoing DVT submuscular reservoir placement abstracted from a large IRB-approved database at our institution. Postimplant cross-sectional imaging performed on many of these patients was used to ascertain the final location of the reservoir. OUTCOMES: Outcome measures included the perioperative and intermediate-term safety and complications of the procedure. Postimplant imaging ascertained the accuracy in providing patients with a submuscular reservoir. RESULTS: There were 107 DVT submuscular reservoirs placed in 100 consecutive patients. No intraoperative complications occurred, there were no postoperative rectus hematomas, and there were 4 (3.7%) postoperative infections. With a mean follow up of 17.5 +/- 20.5 months there was one reservoir herniation, one patient had autoinflation, and one patient required repositioning of a high riding pump. There were 4 mechanical malfunctions requiring revision at a median of 74 months (range: 69-108 months.) following implant placement. Of the 43 patients who underwent imaging: 34 (79%) reservoirs were accurately positioned, 5 (12%) were in the lateral abdominal wall, 1(2%) was in the retroperitoneum, and 3 (7%) were intraperitoneal. Intraperitoneal reservoirs occurred exclusively in postcystectomy patients. CLINICAL IMPLICATIONS: The DVT approach is technically safe, although a slightly higher than expected infection risk was noted. It provides accurate reservoir placement for the majority of imaged patients. Postcystectomy patients have a risk of insidious intraperitoneal reservoir placement. Preoperative counseling should mention this and postimplant imaging may be considered for some of these patients. Imaging may also helpful prior to future revision surgery in order to identify and remove insidious intraperitoneal reservoirs. STRENGTHS AND LIMITATIONS: We investigated 100 patients, almost half underwent cross sectional imaging. Weaknesses include the retrospective nature of this single-institutional study, which may not have similar outcomes at other centers. CONCLUSION: DVT submuscular reservoir placement is safe following pelvic surgery and radiation therapy. Despite careful and deliberate surgical technique imaging found that approximately 20% of reservoirs are not in their expected location. Intraperitoneal reservoirs are of concern, particularly in postcystectomy patients. Kava BR, Levine A, Hauser N, et al. Direct Vision, Transfascial (DVT) Approach to Submuscular Reservoir Placement in Patients Undergoing Multicomponent Penile Implant Surgery Following Prior Pelvic Surgery or Radiation Therapy. J Sex Med 2022;19:394-400.

Optimal cosmetic outcomes for basal cell carcinoma: a retrospective study of nonablative laser management.

Although Mohs micrographic surgery (MMS) is the gold standard for treatment of nonmelanoma skin cancers (NMSCs), laser management has been an emerging treatment option that continues to be studied. Nonablative laser therapy is a noninvasive alternative. This study used a combined pulsed dye laser (PDL) and fractional laser approach to treat basal cell carcinomas (BCCs) in conjunction with noninvasive imaging such as reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) to enhance efficacy rates.

Trans-Fascial Placement of a High, Sub Muscular Reservoir in Patients Following Radical Cystectomy: Safety, Efficacy, and Predictability of Final Reservoir Location Verified With Abdominal Imaging.

INTRODUCTION: With the increasing utilization of ectopic reservoir placement during multicomponent penile implant surgery, safety concerns have been raised about whether passing the reservoir through the floor of the inguinal canal consistently results in placement of the reservoir within the correct location. AIM: To evaluate the safety, efficacy, and patient satisfaction associated with direct-vision, trans-fascial sub muscular reservoir placement in consecutive patients who had previously undergone radical cystectomy. METHODS: Perioperative data, complications, and follow up for the 12 cystectomy patients were evaluated using a comprehensive database of consecutive patients undergoing penile prosthesis placement at our center. Efficacy and patient satisfaction were based upon responses to the Erectile Function and Satisfaction Domains of the International Index of Erectile Function (IIEF). Taking advantage of the need for post cystectomy imaging in monitoring for cancer recurrence, we reviewed post- implant imaging with the purpose of ascertaining the final reservoir location. MAIN OUTCOME MEASURE: Using intraoperative photographs, we describe the technique of trans-fascial sub muscular reservoir placement. Perioperative complications, device efficacy and satisfaction, and the accuracy of reservoir placement are also evaluated. RESULTS: Average patient age was 65 ± 7 years old and the mean time between cystectomy and implant placement was 41 ± 29 months. With a mean follow up of 26 ± 21 months, complications included: 1 reservoir herniation and 1 high riding pump requiring repositioning. Mean IIEF-EF domain was 29.8 ± 0.5 and mean IIEF-satisfaction domain was 17.7 ± 4.5. Other than the herniated reservoir, imaging confirmed accurate reservoir placement in 8 of 9 cases. In 3 patients a small cephalad portion of the reservoir extends posteriorly into the peritoneal or preperitoneal space, with no clinical consequences. CLINICAL IMPLICATIONS: Ectopic reservoir placement using a trans-fascial submuscular approach seems to be a safe method for multicomponent penile implant surgery in patients who have undergone radical cystectomy. Post-implant imaging confirms that the device is consistently placed in the correct sub muscular location. STRENGTHS & LIMITATIONS: This is a novel approach to performing the procedure and a practical manner to ascertain the reservoir position. The limited number of patients prevents generalization of our findings. CONCLUSION: Trans-fascial, sub muscular reservoir placement is a safe means of ectopically placing the reservoir of a multicomponent penile implant following radical cystectomy. Post implant IIEF scores indicate high device efficacy and patient satisfaction. Post implant imaging confirms that the reservoir is almost always in the desired location. Kava BR, Lopatagui DM, Levine A, et al. Trans-Fascial Placement of a High, Sub Muscular Reservoir in Patients Following Radical Cystectomy: Safety, Efficacy, and Predictability of Final Reservoir Location Verified With Abdominal Imaging. J Sex Med 2019;16:338-345.

Introduction to reflectance confocal microscopy and its use in clinical practice.

Reflectance confocal microscopy (RCM) is a novel technology that provides noninvasive, in vivo imaging of the skin at nearly histologic resolution. In 2016, the US Centers for Medicare and Medicaid Services (CMS) established reimbursement codes for RCM image acquisition and for the reading and interpretation of images. The combination of RCM imaging with dermoscopy has improved the accuracy of skin cancer diagnosis while reducing the number of biopsies of benign skin lesions. With that, we are starting to see more dermatologists and dermatopathologists using RCM in clinical practice. This editorial is to serve as an introduction on RCM imaging with a focus on its usefulness in both the diagnosis and management of skin cancers. We end by briefly describing the characteristic RCM features of normal skin to serve as a building block for later cases that will explore both the benefits and drawbacks of incorporating RCM imaging for benign and malignant lesions.

Going digital with dermoscopy.

Digital dermoscopy refers to the acquisition and storage of digital images from a dermoscopic examination. In this article, we delve into the innovative world of digital dermoscopy with a review of its potential uses as well as some nuances of adapting this technology in a clinical setting, including sequential monitoring, teledermoscopy, and machine learning. We also discuss the acquisition and storage of dermoscopy images in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

A review through the looking glass: new advances in dermoscopy.

Dermoscopy is a non-invasive diagnostic technique that facilitates the visualization of surface and subsurface structures of the skin. It has been proven to be an essential tool in the diagnosis of both malignant and benign cutaneous lesions. In this article, we review some of the most recent and noteworthy advances in dermoscopy. In addition, we discuss Reflectance Confocal Microscopy (RCM) and Optical Coherence Topography (OCT), two non-invasive imaging devices that may be used alongside dermoscopy to improve diagnostic accuracy.

Characteristics and Triage of Children Presenting in Mental Health Crisis to Emergency Departments at Detroit Regional Hospitals.

OBJECTIVES: The number of children in the United States utilizing emergency department (ED) services for psychiatric crises is increasing, and psychiatric-related ED visits disproportionately burden hospital resources. Yet, there is limited available information on the epidemiology and outcomes of pediatric mental health emergencies. The present study sought to characterize pediatric mental health-related ED presentations in a large urban center and identify factors predictive of inpatient hospitalization. METHODS: Data were analyzed from a sample of 225 children (120 female and 105 male children), aged 5 to 18 years, who presented in mental health crisis to Detroit regional EDs over a 27-month period. A trained mental health professional used the Crisis Assessment Tool to assess all children. RESULTS: Thirty-eight percent of children presented with severe depression symptoms, and 52% were judged to be at acute risk of suicide, most of whom were female. Sixteen percent of the sample presented with severe psychotic features, and 34% were assessed as being at risk of harming others. Following assessment, 86% of the sample was directed to inpatient treatment, and no sex differences were found in treatment disposition. Risk of suicide, poor judgment, symptoms of psychosis, and risk of danger to others were all found to be significant predictors of subsequent inpatient hospitalization. CONCLUSIONS: Results provide descriptive information regarding child psychiatric emergency presentations in the city of Detroit. The identified factors that help determine triage to inpatient hospitalization suggest areas for possible resource allocation and potential ED-based intervention.

Optical coherence tomography in dermatology.

Optical coherence tomography (OCT), an emerging noninvasive imaging modality, recently received category III Current Procedural Terminology (CPT) codes from the American Medical Association, enabling tracking of its use in the medical community. In this article, we review OCT imaging and its variant systems, discussing its applications and limitations for clinical use. Future directions of OCT technology and goals for obtaining category I CPT codes and reimbursement also are discussed.

Imaging in cutaneous surgery.

Skin cancer is the most commonly diagnosed cancer in the USA. Mohs micrographic surgery is a microscopically controlled surgical technique that excises lateral and deep surgical margins while also sparing function and achieving a good cosmetic outcome. Given the increasing incidence in skin cancer worldwide and its associated treatment costs, techniques are being developed to improve the time and cost efficacy of this procedure. The use of noninvasive imaging, both in vivo and ex vivo, has the potential to increase efficiency of diagnosis and surgical management of skin cancers. These devices are useful in delineating lateral and deep tumor margins prior to surgery in vivo as well as to detect residual tumor ex vivo virtually in real time.

Optical Coherence Tomography in the Diagnosis of Skin Cancer.

Optical coherence tomography (OCT) has emerged as a novel noninvasive imaging device that allows for the real-time, in vivo, cross-sectional imaging of skin morphology. OCT has increased imaging depth and field of view compared with reflectance confocal microscopy, at the cost of decreased cellular resolution. Frequency domain OCT, dynamic OCT (D-OCT), and high-definition OCT (HD-OCT) are useful in the diagnosis, treatment planning, and treatment monitoring of nonmelanoma skin cancers. Research is currently underway to assess the utilization of these devices in distinguishing between malignant and benign melanocytic lesions based on vascular patterns on D-OCT and cellular information on HD-OCT.

In vivo reflectance confocal microscopy.

Reflectance confocal microscopy (RCM) has recently received Category I Current Procedural Terminology (CPT) codes by the Centers for Medicare & Medicaid Services for reimbursement comparable to a skin biopsy. In this article, we present a review of RCM imaging and its benefits and limitations in diagnosis and treatment planning. We also comment on guidelines for receiving reimbursement for acquiring, reading, and interpreting RCM images.

Noninvasive Long-term Monitoring of Actinic Keratosis and Field Cancerization Following Treatment with Ingenol Mebutate Gel 0.015.

OBJECTIVE: To determine whether actinic keratosis and photodamaged perilesional areas (field cancerization) treated successfully with topical ingenol mebutate gel 0.015% remained clear one year later, and to treat actinic keratosis and perilesional skin not treated one year earlier. DESIGN: Single-center, single-arm, open-label extension of an original clinical study completed one year earlier. SETTING: An outpatient clinic. PARTICIPANTS: Fifteen of the original 28 study patients enrolled in and who completed the extension phase. MEASUREMENTS: All treated and untreated lesions in the original study were evaluated clinically, dermoscopically, and with optical coherence tomography at Day 0 of the extension study. Previously untreated lesions were then treated with ingenol mebutate gel 0.015% for three days and reevaluated at Day 60. RESULTS: There was no significant increase in actinic keratoses over one year. The majority of actinic keratoses not treated in the original study were still present at the beginning of the extension study. Following treatment, 69 percent of these lesions cleared by Day 60 of the extension study, which was not significantly different from the 79 percent clearance observed in the original study. CONCLUSION: Ingenol mebutate 0.015% maintained clearance of lesions treated one year earlier. Optical coherence therapy demonstrated its reliability as a noninvasive mode of diagnosis for actinic keratosis as well as actinic damage in the surrounding areas of field cancerization. Optical coherence therapy also showed that previously untreated lesions exhibited similar clearance rates once treated with the medication.

Comorbidity Assessment in Skin Cancer Patients: A Pilot Study Comparing Medical Interview with a Patient-Reported Questionnaire.

Background. Comorbidities are conditions that occur simultaneously but independently of another disorder. Among skin cancer patients, comorbidities are common and may influence management. Objective. We compared comorbidity assessment by traditional medical interview (MI) and by standardized patient-reported questionnaire based on the Adult Comorbidity Evaluation-27 (ACE-27). Methods. Between September 2011 and October 2013, skin cancer patients underwent prospective comorbidity assessment by a Mohs surgeon (MI) and a radiation oncologist (using a standardized patient-reported questionnaire based on the ACE-27, the PRACE-27). Comorbidities were identified and graded according to the ACE-27 and compared for agreement. Results. Forty-four patients were evaluated. MI and PRACE-27 identified comorbidities in 79.5% and 88.6% (p = 0.12) of patients, respectively. Among 27 comorbid ailments, the MI identified 9.9% as being present, while the PRACE-27 identified 12.5%. When there were discordant observations, PRACE-27 was more likely than MI to identify the comorbidity (OR = 5.4, 95% CI = 2.4-14.4, p < 0.001). Overall comorbidity scores were moderate or severe in 43.2% (MI) versus 59.1% (PRACE-27) (p = 0.016). Limitations. Small sample size from a single institution. Conclusion. Comorbidities are common in skin cancer patients, and a standardized questionnaire may better identify and grade them. More accurate comorbidity assessments may help guide skin cancer management.

Gender-specific predictors of retention and opioid abstinence during methadone maintenance treatment.

AIMS: Retention in methadone maintenance treatment (MMT) for 1 year is associated with positive outcomes including opioid abstinence, however, most studies have not investigated gender differences. We hypothesized that predictors of retention and opioid abstinence would differ between men and women, and aimed to determine which factors best predict retention and abstinence for each gender. METHODS: Data were available for 290 patients (173 M, 117 F) admitted to outpatient MMT. Regression analyses, stratified by gender, were conducted to identify unique predictors of MMT retention (<1 vs. >1 year) and opioid abstinence rate (proportion of opioid-free urine samples up to 1 year retention). RESULTS: Gender did not significantly predict treatment retention (mean = 231 days, 39% retained > 1 year) or opioid abstinence (49% overall). For males, significant predictors of > 1-year retention were urine samples negative for opioids (odds ratio [OR] = 6.67) and cannabinoids (OR = 5.00) during the first month, and not cocaine dependent (OR = 2.70). Significant predictors of higher long-term opioid abstinence were first-month urine samples negative for opioids and cocaine metabolites. For females, significant predictors of >1-year retention were first-month urine samples negative for cocaine metabolites (OR = 4.00) and cannabinoids (OR = 9.26), and no history of sexual victimization (OR = 3.03). The only significant predictor of higher opioid abstinence rate was first-month opioid-free urine samples. CONCLUSIONS: These findings indicate gender-specific predictors of MMT retention and opioid abstinence. Future studies on MMT outcomes should examine each gender separately, and consider unique pathways by which females and males adhere to, and benefit from MMT.