Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review.

BACKGROUND: Prophylactic antibiotic therapy is widely used in dermatologic surgery to prevent surgical site infections and bacteremia, which can lead to prosthetic joint infections (PJI) and infective endocarditis (IE) in high-risk populations. OBJECTIVE: To evaluate the incidence of bacteremia, PJI, and IE after dermatologic surgery and assess the current evidence for antibiotic prophylaxis. MATERIALS AND METHODS: A search of the computerized bibliographic databases was performed using key terms from the date of inception to March 21, 2021. Data extraction was performed independently by 2 data extractors. RESULTS: The review resulted in 9 publications that met inclusion criteria, including 5 prospective cohort studies and 4 case reports or case series. The prospective studies reported a wide range of bacteremia incidence (0%-7%) after dermatologic surgery. No cases of PJI resulting directly from cutaneous surgery were identified, and only 1 case series reported IE after various skin procedures. CONCLUSION: These findings suggest a low rate of bacteremia and a lack of direct evidence linking dermatologic surgery to PJI or IE. The scarcity of published data on this topic is a limitation, highlighting the need for further research, particularly randomized controlled trials, to guide antibiotic prophylaxis recommendations.

Exploring the potential role for extended reality in Mohs micrographic surgery.

Mohs micrographic surgery (MMS) is a cornerstone of dermatological practice. Virtual reality (VR) and augmented reality (AR) technology, initially used for entertainment, have entered healthcare, offering real-time data overlaying a surgeon's view. This paper explores potential applications of VR and AR in MMS, emphasizing their advantages and limitations. We aim to identify research gaps to facilitate innovation in dermatological surgery. We conducted a PubMed search using the following: "augmented reality" OR "virtual reality" AND "Mohs" or "augmented reality" OR "virtual reality" AND "surgery." Inclusion criteria were peer-reviewed articles in English discussing these technologies in medical settings. We excluded non-peer-reviewed sources, non-English articles, and those not addressing these technologies in a medical context. VR alleviates patient anxiety and enhances patient satisfaction while serving as an educational tool. It also aids physicians by providing realistic surgical simulations. On the other hand, AR assists in real-time lesion analysis, optimizing incision planning, and refining margin control during surgery. Both of these technologies offer remote guidance for trainee residents, enabling real-time learning and oversight and facilitating synchronous teleconsultations. These technologies may transform dermatologic surgery, making it more accessible and efficient. However, further research is needed to validate their effectiveness, address potential challenges, and optimize seamless integration. All in all, AR and VR enhance real-world environments with digital data, offering real-time surgical guidance and medical insights. By exploring the potential integration of these technologies in MMS, our study identifies avenues for further research to thoroughly understand the role of these technologies to redefine dermatologic surgery, elevating precision, surgical outcomes, and patient experiences.

A national clinician survey on the British Society for Dermatological Surgery guidelines on antithrombotic agent use in skin surgery.

Antithrombotic medication is taken by 14-22% patients undergoing skin surgery, with more patients now taking direct oral anticoagulants (DOACs). The latest evidence suggests that the risk of stopping DOACs perioperatively is low in skin surgery, particularly for primary closures, but remains unclear for more complex procedures. The 2016 British Society for Dermatological Surgery (BSDS) guidelines suggest that clinicians could consider stopping DOACs in patients for 24-48 h, based on individual bleeding risk. We surveyed BSDS members to better understand clinical practice and guideline adherence with a view to updating the guidance. The results demonstrated that there is consistency among clinicians in the management of patients on more established antithrombotic agents, such as aspirin, clopidogrel and warfarin. However, there is a higher perceived risk of significant haematomas following higher-risk procedures such as larger flaps or grafts with DOACs vs. other antithrombotics postoperatively. Stopping DOACs perioperatively for 24-48 h for higher-risk procedures can be cautiously considered following an individual risk assessment and informed discussion with the patient.

An organizational framework for patient-reported outcome instruments in dermatologic surgery: a systematic review and qualitative analysis.

Patient-reported outcomes (PROs) describe measures of a patient's experience throughout medical care as reported by the patient (Mercieca-Bebber et al. in Patient Relat Outcome Meas, 2018). Various PRO instruments exist. It is challenging to select appropriate instruments given the absence of an organizational framework which describes all measurable PROs in dermatologic surgery and represents which instruments measure which outcomes. Our objective was to systematically review all validated PRO instruments in dermatologic surgery and use qualitative analysis to develop an organizational framework representing PRO measures and instruments. PubMed/MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane databases were searched to retrieve validated PRO instruments in the dermatologic surgery population. The constant comparative method of qualitative analysis was used to develop an organizational framework representing all PROs in dermatologic surgery. All instruments were sorted into this framework. The search identified 3195 articles; 35 validated instruments were extracted and qualitatively analyzed. The organizational framework sorted all instruments into 36 PRO measures aligned with the National Institutes of Health Patient-Reported Outcomes Measurement Information System (Gershon RC, Rothrock N, Hanrahan R, et al (2010) The use of PROMIS and assessment center to deliver patient-reported outcome measures in clinical research). Measures were grouped into four categories (expectations, satisfaction, quality of life, needs) describing how patients experience these outcomes and lenses through which researchers can evaluate them. In conclusion, we have proposed an organizational framework for use in choosing validated instruments to develop and answer PRO research questions.

Comisuroplastia mediante colgajo de perforante digital en secuelas cicatriciales de quemaduras / Commissuroplasty using a digital perforator flap in the cicatricial sequelae of burns

Introducción y objetivo: Las bridas cicatriciales en mano como secuela de quemaduras pueden suponer impotencia funcional. El colgajo de perforante de la arteria digital tomado de la cara lateral de los dedos constituye una excelente opción terapéutica para el manejo de estas lesiones. Describimos nuestra experiencia con esta técnica quirúrgica y mostramos sus resultados morfológicos y funcionales. Material y método: Presentamos nuestra experiencia con 14 colgajos en 7 pacientes afectos de bridas comisurales en mano. Estos colgajos, basados en perforantes de la arteria digital, toman como zona donante la cara lateral de la falange proximal adyacente. Cubrimos la zona donante con injertos de piel de espesor total. Los pacientes fueron sometidos a rehabilitación precoz, presoterapia y férulas nocturnas. Resultados: La supervivencia de los colgajos fue completa en los 14 casos. En 1 caso se produjo necrosis del injerto en la zona donante del colgajo, solucionada con curas. Resolvimos la brida comisural en el 85.7 % de los casos (13 de 14 casos). El seguimiento medio fue de 27.3 meses (rango 12-45 meses). En 1 caso se produjo recidiva parcial a los 10 meses, solucionada mediante Z-plastias. Los pacientes experimentaron mejoría subjetiva de la funcionalidad y estética de la mano. La apertura del ángulo del espacio interdigital, medida en grados, mejoró desde una media de 22.5 grados preoperatorios (rango 150-350) a una media de 36.8 grados postoperatorios (rango 250-450). Conclusiones: En nuestra experiencia, el colgajo de perforante de arteria digital es una opción terapéutica rápida, sencilla y eficaz en el tratamiento de las contracturas tras quemaduras del segundo al cuarto espacio interdigital. Son fundamentales el adecuado cuidado postoperatorio, rehabilitación, presoterapia y ferulización para un resultado óptimo.(AU)

Background and objective: Scar contractures in the hand are a sequela of burns that can lead to functional impairment. The perforator flap from the digital artery, taken from the lateral aspect of the fingers, represents an excellent therapeutic option for managing these injuries. We present our experience with this surgical technique and our morphological and functional results. Methods: We present our experience with 14 flaps in 7 patients affected by web contractures in the hand. These flaps, based on perforators from the digital artery, use the adjacent lateral aspect of the proximal phalanx as the donor site. The donor area was covered with full-thickness skin grafts. Patients underwent early rehabilitation, pressure therapy, and nighttime splinting. Results: The survival of the flaps was successful in all 14 cases. One case experienced graft necrosis in the donor site of the flap, which resolved with conservative treatment. Commissural contractures were resolved in 85.7% of the cases (13 out of 14 cases). The mean follow-up period was 27.3 months (range 12-45 months). In 1 case, partial recurrence occurred at 10 months and it was successfully managed with Z-plasty. Patients reported subjective improvement in hand functionality and aesthetics. The interdigital space angle, measured in degrees, improved from a mean of 22.5 degrees preoperatively (range 15°-35°) to a mean of 36.8 degrees postoperatively (range 25°-45°). Conclusions: In our experience, the perforator flap from the digital artery represents a rapid, straightforward, and effective therapeutic option for treating contractures after burns in the second to fourth interdigital spaces. Adequate postoperative care, rehabilitation, pressure therapy and splinting are essential for optimal outcomes.(AU)

Cognitive Task Analysis of Escharotomy.

INTRODUCTION: With the Army's emerging doctrine of prolonged field care, and with burns being a common injury among soldiers, non-expert providers must be trained to perform escharotomy when indicated. However, the existing physical simulators and training protocols are not sufficient for training non-experts for performing effective escharotomy. Hence, to provide guidance in developing realistic escharotomy simulators and effective training protocols suitable for prolonged field care, a cognitive task analysis (CTA) is needed. This work aims to obtain educative information from expert burn surgeons regarding escharotomy procedures via the CTA. MATERIALS AND METHODS: The CTA was done by interviewing five subject matter experts with experience in performing escharotomy ranging from 20 to over 100 procedures and analyzing their responses. Interview questions were developed to obtain educative information from expert burn surgeons regarding the escharotomy procedure. A "gold standard protocol" was developed based on the CTA of each of the subject matter experts. RESULTS: The CTA helped identify general themes, including objectives, conditions that mandate escharotomy, signs of successful escharotomy, precautions, challenges, decisions, and performance standards, and specific learning goals such as the use of equipment, vital signs, performing the procedure, and preoperative and postoperative care. A unique aspect of this CTA is that it identifies the background information and preparations that could be useful to the practitioners at various levels of expertise. CONCLUSIONS: The CTA enabled us to compile a "gold standard protocol" for escharotomy that may serve as a guide for practitioners at various levels of expertise. This information will provide a framework for escharotomy training systems and simulators.