Opioid Prescribing Patterns After Micrographic Surgery: A Follow-up Retrospective Chart Review.

BACKGROUND: The abuse of opioids has reached epidemic proportions in the United States, and leftover medications are a primary source for nonmedical pain relievers. A past study at the University of Utah showed that micrographic surgeons were likely overprescribing opioids, with 35% of patients receiving a postoperative prescription. OBJECTIVE: To examine the current opioid prescribing habits of the micrographic surgeons at the University of Utah compared with those in 2010. METHODS: Retrospective chart review of the patient records of 4 micrographic surgeons between February and May 2017. RESULTS: Four hundred patient visits were reviewed. An opioid prescription was provided after 12% of encounters, 23% lower than in 2010 (p = .004). Younger patient age, increased number of stages and defect size, repair of the defect, and particular surgeons predicted opioid prescription. CONCLUSION: The percentage of patients who received an opioid prescription after undergoing micrographic surgery at the University of Utah decreased from 35% in 2010 to 12% in 2017. Reports of the minimal need of opioids after micrographic surgery, the authors' past study showing an institutional tendency to overprescribe, and reports of the national opioid epidemic likely all contributed to the decrease in opioid prescriptions at the authors' institution.

Benign melanocytic lymph node deposits in the setting of giant congenital melanocytic nevi: the large congenital nodal nevus.

BACKGROUND: Benign melanocytic rests are a frequent finding in superficial lymph nodes removed during sentinel lymph node biopsies for melanoma. Whereas the histopathology of these deposits is well understood, very little is known regarding melanocytic lymph node deposits in the setting of giant congenital melanocytic nevi. METHODS: We analyzed lymph nodes removed from the drainage basin of giant congenital melanocytic nevi in three patients who had developed melanoma within their giant congenital nevi. RESULTS: Two of three patients showed widespread, capsular and parenchymal melanocytic deposits in multiple nodes (9 of 11 nodes in one patient and 6 of 8 in the other). Melanocytes were small, non-mitotically active and resembled those in the associated giant congenital melanocytic nevus. Melanocytes were arranged singly and in small nests ∼0.05 mm in diameter, with some larger sheets up to 1 mm. Nodal melanocytes stained for Melan A and S100 on immunohistochemical evaluation, but showed negative or minimal HMB-45 reactivity. CONCLUSIONS: Evaluation of lymph nodes in the setting of giant congenital melanocytic nevi is complicated by the presence of often numerous, parenchymal melanocytic nevic deposits. Bland cytology and minimal or absent HMB-45 staining may be helpful in differentiating these nodal melanocytic nevi from metastatic melanoma. We term this phenomena large congenital nodal nevus.

Mohs appropriate use criteria: retrospectively applied to nonmelanoma skin cancers at a single academic center.

BACKGROUND: In September 2012, appropriate use criteria (AUC) for Mohs micrographic surgery (MMS) were released by a collaboration of dermatology organizations including the American College of Mohs Surgery. OBJECTIVE: The group sought to determine adherence to the Mohs AUC at the academic institution. MATERIALS AND METHODS: The authors performed a retrospective chart review of all nonmelanoma skin cancers (NMSCs) treated within the University of Utah, Department of Dermatology, from January through March of 2012. They applied the Mohs AUC to analyze these cases. RESULTS: In total, the authors identified 724 patients and 1,026 cases of NMSCs, including 557 (54.3%) basal cell carcinomas and 469 (45.7%) squamous cell carcinomas. Of the 1,026 NMSCs, 350 (34.1%) were treated with MMS. Of these cases treated with MMS, there were 339 cases (96.9%) deemed appropriate, 4 (1.1%) uncertain, and 7 (2.0%) inappropriate per AUC. Also examined were 611 cases treated with modalities other than MMS, of which 60.7% would have met AUC for MMS. CONCLUSION: In a 3-month review of all NMSC cases at the academic center, there is a low percentage of cases performed that are inappropriate for MMS by AUC. At the institution, there is a large percentage of NMSC that meet AUC but are treated by other modalities. The use is highly appropriate for MMS, and these data suggest possible underutilization of MMS for certain NMSCs. Further studies are required to determine the effectiveness of other treatment modalities for NMSC that meet Mohs AUC.

Secondary diffuse large B-cell lymphoma after chemotherapy for acute myeloid leukemia: looking for the unexpected diagnosis.

Development of Epstein-Barr virus (EBV) positive lymphoproliferative disorders in patients with immunosuppression has become more frequently reported. A patient with acute myeloid leukemia was treated to remission, when on follow-up 9 months after his initial diagnosis, he was noted to have a generalized rash and lymphadenopathy. Evaluation of skin and bone marrow biopsies was suggestive of a relapsed leukemia, and treatment was initiated. Fever evaluation revealed a high load of EBV in his blood. A lymph node biopsy and retrospective examination of his skin and bone marrow revealed an EBV-positive diffuse large B-cell lymphoma with no recurrence of acute myeloid leukemia. His chemotherapy-induced immunosuppression likely predisposed him to develop this EBV-positive diffuse large B-cell lymphoma. This case highlights the need to consider a broader differential and immunohistochemical profiling of these neoplasms to avoid misdiagnosing complex oncology patients.

Sentinel lymph node biopsy for melanoma in pregnant women.

BACKGROUND: The incidence of melanoma is rising in young women of childbearing age. Melanoma diagnosed during pregnancy presents unique challenges. This study was conducted to determine the effect of sentinel lymph node biopsy (SLNB) for melanoma on maternal and fetal outcomes in pregnant women. METHODS: A prospective melanoma database was retrospectively queried for women diagnosed with melanoma during or immediately before pregnancy as well as SLNB in pregnant women. The outcomes of SLNB for the mothers and fetuses were evaluated. RESULTS: Fifteen pregnant women underwent wide local excision (WLE) and SLNB for melanoma from 1997 to 2012. The median gestational age was 20 weeks. More than half of the women noticed changes in the primary melanoma lesion during the pregnancy. The median Breslow thickness was 1.00 mm. Lymphatic mapping and SLNB were performed with some combination of radiocolloid or vital blue dye without adverse effects. Three patients had micrometastatic disease and underwent a completion lymphadenectomy. Sixteen children were born at a median gestational age of 39 weeks. The median 1- and 5-minute Apgar scores were 8 and 9, respectively. At a median follow-up of 54.4, months none of the patients had experienced recurrence, and all children were healthy and free of melanoma. CONCLUSIONS: In this series of pregnant women with melanoma, SLNB was performed safely during pregnancy without adverse effects to the mothers and fetuses. We recommend that clinicians explain the risks and benefits of the SLNB procedure to pregnant women so an informed decision can be made about the procedure.

Cold panniculitis following ice therapy for cardiac arrhythmia.

Ice therapy has long been used as first line treatment of supraventricular tachycardia in neonates. We report a case of cold panniculitis developing in a 12-day-old neonate after ice therapy for cardiac arrhythmia. This is the first biopsy-proved case of cold panniculitis following ice therapy for supraventricular tachycardia in a newborn.

Limiting Residency Applications to Dermatology Benefits Nearly Everyone.

With a 34-percent increase in dermatology residency applications in the past decade, residency programs are increasingly faced with the daunting task of reviewing more applications for a relatively fixed number of residency positions. Other specialty programs, including otolaryngology, orthopedics, plastic surgery, and ophthalmology, have called for limiting the number of residency applications. Dermatology programs have developed various ways to decrease the number of reviewed applications, from cutoffs for Step 1 board scores to Alpha Omega Alpha membership to secondary applications. While this can decrease the applicant pool, it limits a more holistic review of applications. We propose an application cap of 20 programs, which will decrease the number of applications each program receives 3- to 5-fold. Each applicant can approach the process more thoughtfully in choosing the best programs for them and will save money in application fees. As program directors rank "perceived interest" in their residency program as a primary factor for selecting applicants, a cap will allow program directors to know that all applicants are interested in their specific program. Ultimately, we contend that application caps would improve match outcomes with applicants receiving training in the best program for them, increasing the likelihood of successful fit for clinical training, opening the field to a more diverse set of applicants, and saving everyone time and money.

Nonmelanoma skin cancers of the ear: correlation between subanatomic location and post-Mohs micrographic surgery defect size.

BACKGROUND: Nonmelanoma skin cancer (NMSC) of the ear can result in large defects with significant morbidity. OBJECTIVE: To determine whether subanatomic location of NMSCs, based on ease of visualization of the ear, correlated with post-Mohs micrographic surgery (MMS) defect size. METHODS: A retrospective chart review of 142 post-MMS ear lesions was performed and categorized according to subanatomic location: the helix, antihelix, and tragus (Location 1); retroauricular (Location 2); and conchal bowl, scapha, and triangular fossa (Location 3). RESULTS: The average defect sizes were 2.50 cm(2) (Location 1), 5.76 cm(2) (Location 2), and 4.03 cm(2) (Location 3). Tumors in Location 1 were significantly smaller than those occurring in Location 2 (P<.001) and Location 3 (P<.01), but a significant difference in size was not seen between Locations 2 and 3 (P=.16). As a control group, we randomly selected 50 NMSC cases from the nose and found the average defect size of nose NMSCs to be 1.58 cm(2). CONCLUSIONS: MMS defects of the ear are larger in nonvisible parts of the ear. As a group, MMS defects on the ear were larger than those on the nose.

AKT1E17K Activates Focal Adhesion Kinase and Promotes Melanoma Brain Metastasis.

Alterations in the PI3K/AKT pathway occur in up to 70% of melanomas and are associated with disease progression. The three AKT paralogs are highly conserved but data suggest they have distinct functions. Activating mutations of AKT1 and AKT3 occur in human melanoma but their role in melanoma formation and metastasis remains unclear. Using an established melanoma mouse model, we evaluated E17K, E40K, and Q79K mutations in AKT1, AKT2, and AKT3 and show that mice harboring tumors expressing AKT1E17K had the highest incidence of brain metastasis and lowest mean survival. Tumors expressing AKT1E17K displayed elevated levels of focal adhesion factors and enhanced phosphorylation of focal adhesion kinase (FAK). AKT1E17K expression in melanoma cells increased invasion and this was reduced by pharmacologic inhibition of either AKT or FAK. These data suggest that the different AKT paralogs have distinct roles in melanoma brain metastasis and that AKT and FAK may be promising therapeutic targets. IMPLICATIONS: This study suggests that AKT1E17K promotes melanoma brain metastasis through activation of FAK and provides a rationale for the therapeutic targeting of AKT and/or FAK to reduce melanoma metastasis.

Facial allergic granulomatous reaction and systemic hypersensitivity associated with microneedle therapy for skin rejuvenation.

IMPORTANCE: Microneedle therapy includes skin puncture with multiple micro-sized needles to promote skin rejuvenation or increase transdermal delivery of topical medications. In cosmetic practices, various cosmeceuticals are applied before microneedling to enhance the therapeutic effects. This results in intradermal tattooing of the topical product. Despite rapid increase in the use of microneedles in dermatology, there are few data about their safety. OBSERVATIONS: We describe 3 women, aged 40s to 60s, who developed open [corrected] facial granulomas following microneedle therapy for skin rejuvenation. Two patients had undergone microinjection of the same branded topical moisturizer (Vita C Serum; Sanítas Skincare) during microneedle therapy. Biopsy in all cases showed foreign body-type granulomas. Results of tissue cultures were negative. Chest radiography and serum angiotensin-converting enzyme findings were normal. The first 2 patients had a positive patch test reaction to Vita C Serum. Initial treatment with topical and oral corticosteroids was ineffective. Therapy with doxycycline hydrochloride and minocycline hydrochloride led to partial improvement in one case and resolution in another. CONCLUSIONS AND RELEVANCE: Application of topical products prior to microneedling can introduce immunogenic particles into the dermis and potentiate local or systemic hypersensitivity reactions. Because the microneedle therapy system is accessible for home use, health care providers need to be aware of its potential consequences.