Association of Postoperative Antibiotics With Surgical Site Infection in Mohs Micrographic Surgery.

BACKGROUND: Surgical site infection (SSI) is the most frequent complication of Mohs micrographic surgery. Previous studies have identified risk factors for SSI, but it is not known whether antibiotic prophylaxis mitigates this risk. OBJECTIVE: To measure the association between antibiotic prophylaxis and SSI in a convenience sample of Mohs cases and to report on the utility of propensity scoring to control for confounding by indication in registry data. METHODS: Data were drawn from a pilot quality improvement registry of 816 Mohs cases. The relationship between antibiotic prophylaxis and SSI was assessed with logistic regression modeling using propensity score methods to adjust for confounding. RESULTS: One hundred fifty-one cases were prescribed antibiotic prophylaxis (18.5%). Of 467 cases with follow-up, 16 (3.4%) developed SSI. Infection rates were higher in subjects prescribed prophylaxis, but propensity adjustment reduced this effect. Adjusted odds of infection were 1.47-fold higher in subjects prescribed antibiotics and not statistically significant (95% confidence interval 0.29-7.39; p = .64). CONCLUSION: Although there was no significant difference in SSI among patients prescribed prophylactic antibiotics, statistical precision was limited by the low incidence of infection. Larger population-based prospective registry studies including propensity adjustment are needed to confirm the benefit of prophylactic antibiotics in high-risk surgical cases.

Performance Measures in Dermatologic Surgery: A Review of the Literature and Future Directions.

BACKGROUND: In recent years, health care reform initiatives have aimed to assess quality of care through the use of performance measures. Multiple specialties, including dermatology, have implemented registries to track and report health care quality. OBJECTIVE: The authors review the history and rationale for assessing quality in dermatologic surgery. The authors also discuss the different types of performance measures and the current efforts to develop clinically relevant dermatologic surgery-specific measures. MATERIALS AND METHODS: An extensive literature review was conducted using OVID, MEDLINE, PubMed, and government and health care-related websites to identify articles related to surgical performance measures. RESULTS: Few performance measures are established to assess quality in dermatologic surgery. The authors propose specific candidate measures and discuss how clinical registries can capture measures that meet federal reporting requirements. CONCLUSION: Assessment of health care quality will become increasingly important in health care reform. Physicians need to take an active role in selecting appropriate, clinically relevant performance measures that will help improve patient care while containing health care costs and meeting government-mandated reporting requirements.

Perioral wrinkles are associated with female gender, aging, and smoking: Development of a gender-specific photonumeric scale.

BACKGROUND: Perioral wrinkling is commonly reported among older adults, but its objective evaluation and causes remain poorly understood. OBJECTIVE: We sought to develop a photonumeric scale for perioral wrinkling and to elucidate contributory lifestyle factors. METHODS: In this cross-sectional study, we recruited participants for facial photographs and a survey. A gender-specific photonumeric scale for perioral wrinkling was developed and used by 3 graders to evaluate participant photographs. Scores and survey responses were used to create a multiple regression model to predict perioral wrinkling. RESULTS: In all, 143 participants aged 21 to 91 years were enrolled. Intraclass correlation coefficient values for interrater and intrarater reliability were high (>0.8) across 2 trials and 3 graders. A multiple regression model for prediction of perioral wrinkling severity included age, gender, and years of smoking as variables. LIMITATIONS: The study was limited by sample size and a predominantly Caucasian study population. CONCLUSION: We created a photonumeric scale that accounts for gender differences in perioral wrinkling and highlighted contributory variables to photoaging in this anatomical location.

Histopathological features of molluscum contagiosum other than molluscum bodies.

AIMS: Classic histopathological features of molluscum contagiosum (MC) include a crateriform, acanthotic epidermis containing intracytoplasmic molluscum bodies (MBs). In our experience, a subset of cases lack these features on initial haematoxylin and eosin-stained sections. We aimed to describe the histopathological features of MC other than those classically described. METHODS AND RESULTS: Sixty-seven biopsies diagnosed as MC from January 2011 to October 2012 were retrospectively reviewed. Keratinocytes peripheral to the diagnostic cells with MBs had prominent nucleoli (67; 100%), amphophilic cytoplasm (54; 81%), and in many instances clear cytoplasmic vacuolization (38; 57%). Stroma surrounding MC lesions showed fibroedematous to fibromyxoid changes in many cases (36; 54%), with a subset (13; 19%) showing abundant dermal mucin. In eight of 67 cases (12%), initial sections did not possess MBs or crateriform epidermis of MC. In these cases, initial sections revealed only the epithelial and/or perilesional stromal changes described above. Additional sections contained MBs in all of these cases. CONCLUSIONS: Perilesional fibroedematous to fibromyxoid stroma and keratinocyte changes, including prominent nucleoli and amphophilic cytoplasm with clear vacuolization, are common in MC. Recognizing these features may prove helpful in reaching the diagnosis of MC in cases lacking classic histopathological features on initial sections.

Perceptions and impact of patient reviews: a survey of academic dermatologists.

BACKGROUND: Patient reviews (PRs) have emerged as a method to assess patient experiences with healthcare in order to improve the quality of care. Both institutional and third-party organizations collect quantitative data and comments from these patient surveys, usually accessible to the public for review. Our study examined dermatologists' perceptions of PRs and assessed their impact on dermatologists. METHODS: A survey was sent to the Association of Professors of Dermatology listserv (response rate 30%). RESULTS: Most respondents disagreed with the statements that PRs are good for doctors (63%), good for patients (58%), helpful for doctors (58%), or that high PRs indicate being a good doctor (65%). The majority disagreed that PRs should be available publicly (60%). Respondents agreed that PRs contribute to depersonalization (60%), energy depletion or exhaustion (55%), added stress at work (70%), negativism/cynicism about work (60%), and diminished professional efficacy (29%). Self-identified female respondents were more likely to agree that PRs added stress to work compared to self-identified males (66% vs. 42%, P < 0.05). CONCLUSIONS: Overall, these findings suggest that PRs may negatively impact dermatologists' well-being and perceived stress levels.

An unusual presentation and distribution of generalized eruptive syringomas.

A 19-year-old Caucasian man presented with numerous erythematous to flesh-colored papules that appeared in crops on his neck, axillae, buttocks, and lower back. The lesions started on his anterior neck at age 12. At 18 years, new crops of papules appeared on his axillae, back, and buttocks over several months. He reported pruritus in the lesions following exercise and perspiration. He denied any family history of similar lesions. His primary care physician treated him with topical triamcinolone 0.1% cream, which made the lesions smaller, less erythematous, and less pruritic; however, the papules never fully resolved. After discontinuation of the steroids, these erythematous pruritic papules gradually recurred in the same areas of his body. The patient denied any other medical complaints.

Noninvasive imaging of angiogenesis with a 99mTc-labeled peptide targeted at alphavbeta3 integrin after murine hindlimb ischemia.

BACKGROUND: Noninvasive imaging strategies play a critical role in assessment of the efficacy of angiogenesis therapies. The alpha(v)beta3 integrin is activated in angiogenic vessels and represents a potential target for noninvasive imaging of angiogenesis. METHODS AND RESULTS: We evaluated a 99mTc-labeled peptide (NC100692) targeted at alpha(v)beta3 integrin for imaging in an established murine model of angiogenesis induced by hindlimb ischemia. Control mice (n=9) or mice with surgical right femoral artery occlusion (n=29) were injected with NC100692 (1.5+/-0.2 mCi IV) at different times after femoral occlusion (1, 3, 7, and 14 days) for in vivo pinhole planar gamma camera imaging. Tissue from hindlimb proximal and distal to occlusion was excised for gamma well counting and for immunostaining. On in vivo pinhole images, increased focal NC100692 activity was seen distal to the occlusion at days 3 and 7. This increase in relative NC100692 activity was confirmed by gamma well counting. Lectin staining confirmed increased angiogenesis in the ischemic hindlimb at these time points. A fluorescent analogue of NC100692 was used to confirm specificity and localization of the targeted tracer in cultured endothelial cells. In addition, endothelial cell specificity was confirmed on tissue sections with the use of dual immunofluorescent staining of endothelium and the fluorescent analogue targeted at the alpha(v)beta3 integrin. CONCLUSIONS: A 99mTc-labeled peptide (NC100692) targeted at alpha(v)beta3 integrin selectively localized to endothelial cells in regions of increased angiogenesis and could be used for noninvasive serial "hot spot" imaging of angiogenesis. This targeted radiotracer imaging approach is a major advance in tracking therapeutic myocardial angiogenesis and has an important clinical potential.

Noninvasive targeted imaging of matrix metalloproteinase activation in a murine model of postinfarction remodeling.

BACKGROUND: Time-dependent activation of matrix metalloproteinases (MMPs) after myocardial infarction (MI) contributes to adverse left ventricular (LV) remodeling; however, noninvasive methods to monitor this process serially are needed. METHODS AND RESULTS: MMP-targeted radiotracers were developed that displayed selective binding kinetics to the active MMP catalytic domain. Initial nonimaging studies were performed with a (111)In-labeled MMP-targeted radiotracer ((111)In-RP782) and negative control compound ((111)In-RP788) in control mice (Ctrl) and in mice 1 week after surgically induced MI. Localization of (111)In-RP782 was demonstrated within the MI by microautoradiography. A 334+/-44% increase (P<0.001 versus Ctrl) in relative retention of (111)In-RP782 was confirmed by gamma well counting of myocardium. Subsequent high-resolution dual-isotope planar and hybrid micro-single-photon emission computed tomography/CT imaging studies with an analogous 99mTc-labeled MMP-targeted radiotracer (99mTc-RP805) and 201Tl demonstrated favorable biodistribution and clearance kinetics of 99mTc-RP805 for in vivo cardiac imaging, with robust retention 1 to 3 weeks after MI in regions of decreased 201Tl perfusion. Gamma well counting yielded a similar approximately 300% increase in relative myocardial retention of 99mTc-RP805 in MI regions (Ctrl, 102+/-9%; 1 week, 351+/-77%; 2 weeks, 291+/-45%; 3 weeks, 292+/-41%; P<0.05 versus Ctrl). Myocardial uptake in the MI region was also significantly increased approximately 5-fold when expressed as percentage injected dose per gram tissue. There was also a significant 2-fold increase in myocardial activity in remote regions relative to control mice, suggesting activation of MMPs in regions remote from the MI. CONCLUSIONS: This novel noninvasive targeted MMP radiotracer imaging approach holds significant diagnostic potential for in vivo localization of MMP activation and tracking of MMP-mediated post-MI remodeling.