A Rare Case of a Basomelanocytic Tumor.

ABSTRACT: Basal cell carcinomas and melanoma are common cutaneous malignancies. However, the development of a basomelanocytic tumor that simultaneously includes elements of melanoma and basal cell carcinoma is extremely rare. We present the case of an 84-year-old man who presented with a nonpigmented, nonulcerated pink nodule of his left upper back and discuss the current management recommendations for basomelanocytic tumors.

Virtual lesion clinic - Evaluation of a teledermatology triage system for referrals for suspected melanoma.

INTRODUCTION: The Virtual Lesion Clinic (VLC) of Waitemata District Health Board (WDHB) improves melanoma assessment and treatment using teledermatology. The VLC is reserved for pigmented lesions referred as suspected melanoma from primary care but indeterminate at the initial triage. OBJECTIVES: To assess the efficacy of the VLC diagnosis of melanoma. METHODS: A retrospective audit of suspected melanoma referrals (1 January 2012 to 31 December 2016) was conducted. Lesions were referred to the VLC if diagnostic uncertainty remained at the initial triage. VLC patients attended MoleMap imaging centres, a dermatologist reviewed history and images remotely and suggested a diagnosis and management plan. Post VLC provisional diagnosis of melanoma, all lesions subsequently excised were reviewed. A positive predictive value (PPV) was calculated using concordance between VLC diagnosis of melanoma and histopathological diagnosis of melanoma. Number needed to excise (NNE) for melanoma was derived, as well as an invasive to in-situ melanoma ratio (IM:MIS) and false negative rate (FNR). RESULTS: The VLC received 1874 referrals for 3546 lesions during the 5-year study period. Six hundred and seventy-nine lesions were recommended excision/biopsy or specialist face-to-face assessment, and 504 lesions were subsequently excised. The PPV was 62%, NNE 1.62 and IM:MIS 0.76 for lesions suspected to be melanoma at VLC assessment. The VLC had a melanoma-specific FNR of 7%. CONCLUSIONS: The VLC is effective in early diagnosis of melanoma with a high positive predictive value, low number needed to excise and low false negative rate amongst lesions referred as suspected melanoma.

Functional and structural networks of lateral and medial orbitofrontal cortex as potential neural pathways for depression in childhood.

BACKGROUND: Converging evidence suggests that the lateral and medial orbitofrontal cortices (lOFC and mOFC) may contribute distinct neural mechanisms in depression. This study investigated the relations of their functional and structural organizations with postnatal maternal depressive symptoms in young children. METHODS: Resting-state functional magnetic resonance imaging and structural magnetic resonance imaging were acquired in children at age 4 (n = 199) and 6 years (n = 234). Child's withdrawal behavior problems were assessed using Child's Behavior Checklist. RESULTS: In 4-year-old girls, postnatal maternal depressive symptoms were positively associated with the lOFC functional connectivity with the visual network but negatively with the cognitive control network. The lOFC functional connectivity with the visual network and cerebellum, which was influenced by postnatal maternal depressive symptoms, was also associated with child's withdrawal behavior problems in 6-year-old girls. Moreover, postnatal maternal depressive symptoms were also negatively associated with the mOFC functional connectivity with the cognitive control and motor networks in 4-year-old girls. Furthermore, postnatal maternal depressive symptoms influenced the structural connectivity of left mOFC with the right middle frontal cortex and left inferior temporal cortex in 4-year-old girls. Unlike girls, boys showed that postnatal maternal depressive symptoms selectively impacted the mOFC functional connectivity with the memory system at age 6 years. CONCLUSION: Our study provided novel evidence on the distinct neural mechanisms of the lOFC and mOFC structural and functional organizations for intergenerational transmission of maternal depression to the offspring. Boys and girls may potentially employ different neural mechanisms to adapt to maternal environment at different timings of early life.

Perinatal maternal depressive symptoms alter amygdala functional connectivity in girls.

Perinatal maternal depressive symptoms influence brain development of offspring. Such effects are particularly notable in the amygdala, a key structure involved in emotional processes. This study investigated whether the functional organization of the amygdala varies as a function of pre- and postnatal maternal depressive symptoms. The amygdala functional network was assessed using resting-state functional magnetic resonance imaging (rs-fMRI) in 128 children at age of 4.4 to 4.8 years. Maternal depressive symptoms were obtained at 26 weeks of gestation, 3 months, 1, 2, 3, and 4.5 years after delivery. Linear regression was used to examine associations between maternal depressive symptoms and the amygdala functional network. Prenatal maternal depressive symptoms were significantly associated with the functional connectivity between the amygdala and the cortico-striatal circuitry, especially the orbitofrontal cortex (OFC), insula, subgenual anterior cingulate (ACC), temporal pole, and striatum. Interestingly, greater pre- than post-natal depressive symptoms were associated with lower functional connectivity of the left amygdala with the bilateral subgenual ACC and left caudate and with lower functional connectivity of the right amygdala with the left OFC, insula, and temporal pole. These findings were only observed in girls but not in boys. Early exposure to maternal depressive symptoms influenced the functional organization of the cortico-striato-amygdala circuitry, which is intrinsic to emotional perception and regulation in girls. This suggests its roles in the transgenerational transmission of vulnerability for socio-emotional problems and depression. Moreover, this study underscored the importance of gender-dependent developmental pathways in defining the neural circuitry that underlies the risk for depression.

Exploring melanoma shifts: a two-decade analysis in New Zealand.

AIMS: New Zealand melanoma incidence rates are amongst the highest in the world. The study aims to provide information on the incidence of cutaneous melanoma in New Zealand from 2000 to 2022. METHODS: De-identified data were extracted from the New Zealand Cancer Registry using the ICD-10 code for malignant melanoma (C34) and melanoma in situ (MIS) (D03) from 2000 to 2022. Statistical analysis was performed to calculate melanoma incidence rates. RESULTS: Invasive melanoma (IM) incidence rates demonstrated an increasing trend from 2000 to 2008 (+1.10 per 100,000 person-years per year), followed by an inflection point at 2008 and then a decreasing trend from 2008 to 2022 (-0.28 per 100,000 person-years per year), which was not statistically different from zero/no change. MIS incidence increased from 30.3 to 72.1 per 100,000 person-years between 2000 and 2022. CONCLUSIONS: The incidence of IM in New Zealand has plateaued in the last decade and was associated with an increase in MIS incidence over the same period. While this trend is encouraging, further research is required to investigate whether there is an actual decline in IM incidence.

New Zealand patients have a higher melanoma burden in sentinel nodes and completion lymphadenectomy than patients in MSLT-II.

New Zealand has the highest rate of melanoma-related mortality in the world. Access to immunotherapy and radiology is limited and surgical treatment of regional disease remains important. A recent pilot study of a single health district observed a higher nodal melanoma burden than was reported in the second Multicentre Selective Lymphadenectomy Trial (MSLT-II). In this study, a series of regional censuses were undertaken covering the 10 years immediately prior to the publication of MSLT-II. The study population was seven District Health Boards covering 62.2% of the population of New Zealand across a 10-year period preceding MSLT-II. The primary outcomes measured were the size of sentinel lymph node metastases and non-sentinel node (NSN) positivity on completion lymph node dissection (CLND) for patients with a positive sentinel lymph node biopsy (SLNB). In the 2323 SLNB identified, the mean sentinel lymph node metastatic deposit size was larger compared to MSLT-II (2.55 vs. 1.07/1.11 mm). A greater proportion of New Zealand patients (44.2%) had metastatic deposits larger than 1 mm compared to MSLT-II (33.2/34.5%) and the rate of non-sentinel node involvement on CLND was also higher (22.2% vs. 11.5%). These findings indicate that New Zealand is a high-risk population for nodal melanoma metastases. Due to these differences, the conclusions of MSLT-II may not be able to be applied to melanoma patients in the 7 regions studied in New Zealand.

Predictors of maternal distress among mothers in economic hardship: A classification and regression tree analysis (CART).

A recurrent observation in poverty research is the association between many attendant stress factors and the high incidence of maternal distress. In this study, we reason that such risk factors do not preclude mothers from possessing adaptive capacities, through perceived parenting efficacy and family hardiness, as buffers against two common distress sources in low socioeconomic status (SES) households-perceived children's emotional and behavioral problems, and family's economic hardship. Using classification and regression tree analysis, we examined the moderating roles of these maternal factors in emotional distress with 513 Singaporean mothers of elementary school-age children on government financial scheme. The study affirmed that this low-resource population is not homogeneous in their perceived levels of distress and adaptive resources. These factors moderated mothers' distress along different pathways. Parenting efficacy emerged as the most important predictor across different maternal distress levels. Perceived family hardiness behaved in a unique way, evident only with mothers who reported moderate-severe distress levels. Almost half the respondents reported normal-mild distress levels. Economic hardship did not emerge as a significant predictor. The findings reiterate the usefulness of attending to both situation-specific personal efficacy beliefs and trait-like family hardiness in their potential values to buffer mothers living under economic strain. Research and practice implications were identified. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Selective internal radiation therapy for hepatic metastases of uveal melanoma: a systematic review.

OBJECTIVE: Uveal melanoma (UM) commonly metastasizes to the liver. Treatment usually consists of liver-directed therapies, such as selective internal radiation therapy (SIRT). This review aimed to assess the effectiveness and safety of SIRT for hepatic metastases from UM. METHODS: The study protocol is available at OSF (https://osf.io/vhyct/). EMBASE and MEDLINE were searched until July 2020, using terms related to SIRT and hepatic metastases from UM. Studies reporting outcomes of SIRT in patients with UM and at least one hepatic metastasis were included. Data on overall survival (OS), hepatic progression free survival (hPFS) or tumor response were collected. The Newcastle-Ottawa Scale (NOS) was used to assess risk of bias. RESULTS: 11 studies were included, reporting outcomes for 268 patients with hepatic metastases from UM. Most studies (n = 9, 81.8%) were retrospective. Disease control was achieved in 170 patients (67.5%) and the median OS from time of SIRT was 12.3 months. Median hPFS was 5.4 months. Low-grade side-effects were common but serious complications were infrequent. There were two treatment-related deaths. The median NOS score was 6 (moderate risk of bias). CONCLUSION: SIRT appears to be a safe and effective treatment for patients with unresectable hepatic metastases from UM. The certainty of our results is unclear due to predominantly retrospective data with moderate risk of bias. Further prospective studies are required to explore the role of SIRT in UM. ADVANCES IN KNOWLEDGE: SIRT appears to be a safe treatment for patients with unresectable hepatic metastases from UM. Further prospective work is required.

Why did COVID-19 not further harm the mental health of poor mothers? A mixed-method study on low-income families in Singapore.

OBJECTIVES: This paper examines the impact of COVID-19 pandemic on a disadvantaged group of financially poor mothers' mental health conditions in Singapore during the phase of acute COVID-19 infection. DESIGN: A mixed-method design is used. We conducted five focus group discussions with interviewers (n=39) who administered a third wave of survey questionnaire to 424 mothers from low-income families between June and September 2020. The focus group discussions gleaned observations by the interviewers on the risk and stress levels of the mothers during the period leading up to the height of COVID-19 pandemic. In addition, survey data from two time points-pre-COVID-19 and post-COVID-19 pandemic height, measuring the relationship of mother's job loss, income earner loss, marital status, number of children and, permanency of employment and mother's hope levels with mother's depression and anxiety were used to triangulate the observations from the focus group discussions. RESULTS: Majority of the interviewers did not observe any marked increase in stress levels. Correspondingly the quantitative data did not show any significant increase in depression and anxiety scores between wave 2 and 3 results. Qualitative data showed that numerous mothers were able to report different strategies in coping with the financial distress. The government COVID-19 support grants were cited by many as helpful in cushioning the financial stress. Comparing the quantitative measurements, the relationship between loss of income earner and mother's depression and anxiety was moderated by marital status. In addition, the relationship between mother's job loss and mother's depression, as well as loss of income earner and mother's anxiety, was moderated by mother's hope. CONCLUSION: We speculate the relatively stable level of mental health state of financially poor mothers amidst the COVID-19 pandemic to their internal (psychological traits) resilience which is facilitated by the availability of resources in the social milieu through the COVID-19 support grants.

Proposed quality performance indicators of sentinel lymph node biopsy for cutaneous melanoma.

BACKGROUND: Melanoma is a leading cause of morbidity and mortality in Australia and New Zealand. New Zealand has the highest melanoma incidence in the world alongside Australia at 54 per 100 000 persons. The aim of this study is to conduct a retrospective quality audit of sentinel lymph nodal biopsy (SLNB) practices from 2007 to 2019 of a high-volume melanoma surgeon. Primary outcome was false negative rate (FNR). Secondary outcomes were sentinel node (SN) identification and removal rate, and complication rates. METHODS: A database was maintained, containing n = 553 consecutive SLNB's for cutaneous melanoma from 31 August 2007 to 31 August 2019. Patient characteristics and details of the primary lesion, sentinel lymph node biopsy, recurrence and complications were recorded. RESULTS: SN's were successfully identified in 444 (99.6%) out of 446 patients with an FNR of 9.1%. Positive SN's were identified in 70 (12.7%) SLNB's. Complications occurred in 76 out of 553 (13.7%) SLNB's. A review of internationally published literature reveals an SN identification rate of 94.4-99.5% with an FNR of 4.0-37.5%. SLNB is the best staging tool for melanoma and gives potential access to adjuvant systemic treatment if >1 mm deposits are found. It is a day-stay procedure with a low-complication rate. CONCLUSION: SLNB is a safe and reliable procedure utilized for cutaneous melanoma. We propose our data should be used alongside international SN series to establish Quality Performance Indicators to improve melanoma management.

Proposed Quality Performance Indicators (QPI's) for axillary lymphadenectomy in metastatic cutaneous melanoma.

INTRODUCTION: Axillary lymph node clearance (ALNC) continues to play a central role in the management of melanoma. However, what defines an adequate lymphadenectomy remains unclear. We aimed to propose Quality Performance Indicators (QPIs) for ALNC and to determine if the number of lymph nodes (LNs) removed impacts survival. METHODS: We reviewed patients who underwent ALNC for melanoma at the Waitemata District Health Board and Melanoma Unit between February 2005 and October 2019, performed by two surgeons with standardized technique and surveillance. RESULTS: 105 patients with stage III melanoma were included, of which 73 had clinically evident disease and 32 had clinically occult disease. The mean total number of LNs excised was 29 (SD 10.90, range 10-76). On multivariate analysis, lymph node ratio (HR 4.48, 95% CI 1.55-12.93, p = 0.006), extracapsular spread (HR 2.53, 95% CI 1.06-6.05, p = 0.036) and distant recurrence (HR 11.24, 95% CI 3.79-33.31, p < 0.001) were significant predictors of mortality. The number of LNs removed did not predict survival outcomes, while the lymph node ratio did significantly predict survival outcomes. The regional recurrence rate was 3.8%. DISCUSSION: We propose that QPIs for ALNC in melanoma include a 90th percentile LN yield of greater than 15, a mean LN yield of 20, a regional recurrence rate of less than 10%, and an overall complication rate of less than 50%. CONCLUSION: The establishment of QPIs can help ensure that surgical oncology patients receive the highest quality of care.

Morbidity following thyroid and parathyroid surgery: Results from key performance indicator assessment at a high-volume centre in New Zealand.

BACKGROUND: Complications following thyroid/parathyroid surgery include recurrent laryngeal nerve (RLN) injury, hypocalcaemia and return to theatre for haematoma evacuation. Rates of these form the basis of key performance indicators (KPI). An endocrine database, containing results from 1997, was established at the North Shore Hospital in Auckland, New Zealand. We aimed to measure complication rates by procedure (thyroid and parathyroid), explore a temporal change in our unit and compare our results against international literature. METHODS: A retrospective review of the database between July 1997 and February 2020 was performed. The results for each KPI were analysed in total and over consecutive time periods. A review of the literature was carried out to find international complication rates for comparison. A cumulative sum (CUSUM) analysis was performed to give visual feedback on performance. RESULTS: There were 1062 thyroidectomies and 336 parathyroidectomies from July 1997 to February 2020. Thyroid surgery results found rates of temporary/permanent RLN injury of 1.9%/0.3%, temporary/permanent hypocalcaemia of 22.3/2.5%, and return to theatre for haematoma evacuation of 1.1%. Parathyroid surgery results were, temporary RLN injury of 0.8% (no permanent injury), temporary/permanent hypocalcaemia of 1.7%/0.4%, and return to theatre for haematoma evacuation of 0.3%. CUSUM analysis found KPI results to be comparable with international literature. CONCLUSION: Our unit's KPI results are comparable to published results in the literature. The use of this clinical database will help in future monitoring of performance and help drive improvement in the service. Embedding prospective data collection as routine practice allows for continuous improvement for the unit.

Quality assessment of a large primary GP skin cancer service in Auckland, New Zealand.

AIM: Waitemata District Health Board has implemented a new approach to the management of skin cancers by triaging lesions to specialist-trained general practitioners (GPSI) with the aim of reducing patient wait times and treatment costs. The primary outcome was to determine positive margin rates for the GP surgeons, with secondary outcome being infection rates. METHOD: A retrospective audit was conducted on all excisions (n=2,705) performed between 1 January 2016 and 31 December 2016 by the 13 WDHB GPSIs. Electronic patient records were accessed to review data. Each lesion was classified into benign, in-situ (pre-malignant) and malignant categories. Surgical margins were analysed for non-melanotic skin cancers (NMSC) and determined as positive, close or negative. Infection rates determined by microbiology results and prescribing information and time to treat analyses were conducted. RESULTS: WDHB GPSIs performed 2,705 excisions, 1,887 (69.8%) of which were malignant lesions. Among the 1,486 NMSC excised, a positive surgical margin was observed in 51 (3.4%). There were 294 (10.9%) cases of infection in 2,705 excisions. Median time to treat was 31 days across all lesions. New Zealand papers from the last two decades estimate the NMSC positive margin rate among primary care physicians varies between 16-31%; most recent papers have published rates 6.8-9.5%.European publications describe positive margin rates ranging between 13.9-33.5%. CONCLUSION: This study validates the use of surgically trained GP surgeons and shows their integral role in managing the high volume of skin cancer in New Zealand.

Maternal care in infancy and the course of limbic development.

Maternal care may predict limbic development, though relations may vary by age and type of assessment. Here, we examined maternal behavior during early infancy (i.e., six months postpartum) in relation to offspring hippocampal and amygdala volume and microstructure development between 4.5 (n = 99) and 6 (n = 111) years. In interaction with offspring sex, maternal sensitivity predicted left amygdala volume at 6.0 years (ß=-0.214, p = 0.032, df = 89) and independently predicted predominately left lateralized aspects of amygdala and hippocampal microstructure at both time points (hippocampus: left FA at 4.5 years [ß=-0.241, p = 0.043, df = 68], and, in interaction with sex, left [(ß = 0.349, p = 0.022, df = 86) and right FA at 6 years (ß = 0.357, p = 0.016, df = 86] and left MD growth [ß = -0.517, p = 0.021, df = 37]; amygdala: left MD at 4.5 years [ß = -0.319, p = 0.007, df = 69] and, in interaction with offspring sex, left MD growth [ß = -0.546, p = 0.019, df = 37]). Results suggest exposure to non-extreme, early insensitive care impacts neuroanatomy important to learning and stress regulation, perhaps by accelerating development. This underscores the need to promote sensitive caregiving during early infancy within community samples.

Long-term Influences of Prenatal Maternal Depressive Symptoms on the Amygdala-Prefrontal Circuitry of the Offspring From Birth to Early Childhood.

BACKGROUND: Prenatal maternal depression may have long-term impacts on amygdala-cortical development. This study explored associations of prenatal maternal depressive symptoms on the amygdala-cortical structural covariance of the offspring from birth to early childhood, derived from a longitudinal birth cohort. METHODS: Structural magnetic resonance imaging was performed to obtain the amygdala volume and cortical thickness at each time point. Prenatal maternal depressive symptoms were measured using the Edinburgh Postnatal Depression Scale at 26 weeks of pregnancy. Regression analysis was used to examine the effects of the Edinburgh Postnatal Depression Scale on a structural coupling between the amygdala volume and cortical thickness at birth (n = 167) and 4.5 years of age (n = 199). RESULTS: Girls whose mothers had high prenatal maternal depressive symptoms showed a positive coupling between the amygdala volume and insula thickness at birth (ß = .617, p = .001) but showed a negative coupling between the amygdala volume and inferior frontal thickness at 4.5 years of age (ß = -.369, p = .008). No findings were revealed in boys at any time point. CONCLUSIONS: The development of the amygdala-prefrontal circuitry is vulnerable to environmental factors related to depression. Such a vulnerability might be sex dependent.

Concomitant choroidal inflammation during anterior segment recurrence in Vogt-Koyanagi-Harada disease.

PURPOSE: To determine whether clinically isolated anterior segment recurrence is associated with concomitant subclinical choroidal inflammation in Vogt-Koyanagi-Harada (VKH) disease. DESIGN: Interventional, retrospective case series. METHODS: Nine patients with recurrent VKH disease who satisfied the following criteria: 1) presence of anterior chamber (AC) inflammation of at least 1+ cells after a period of quiescence of three months or more, 2) no posterior segment involvement, and 3) indocyanine green angiography (ICGA) performed during the time of anterior segment recurrence at the Singapore National Eye Centre. ICGA was performed. Therapy was administered based on clinical features. The main outcome measures were the ICGA features. RESULTS: Twelve eyes of nine patients were included in the study. All eyes had mild AC inflammation of 1 to 2+ cells, except for one eye that had 3+ cells. ICGA showed early large vessel hyperfluorescence, becoming fuzzy in character in the intermediate phase in 11 of 12 eyes with AC inflammation. In four eyes, few hypofluorescent dots were seen in the intermediate phase that remained hypofluorescent in the late phases. Late diffuse hyperfluorescence was observed in five eyes. All patients received high-dose oral prednisolone and topical prednisolone acetate. Four patients required additional steroid-sparing immunosuppressants. All patients attained clinical quiescence within two weeks to two months. Repeat ICGA showed absence of active leakage, significant decrease in choroidal vascular leakage, or no change in the number and density of hypofluorescent spots. CONCLUSIONS: Isolated anterior segment recurrence in VKH disease may occur concomitantly with subclinical choroidal inflammation and requires systemic therapy.

Pre- and Post-Natal Maternal Depressive Symptoms in Relation with Infant Frontal Function, Connectivity, and Behaviors.

This study investigated the relationships between pre- and early post-natal maternal depression and their changes with frontal electroencephalogram (EEG) activity and functional connectivity in 6- and 18-month olds, as well as externalizing and internalizing behaviors in 24-month olds (n = 258). Neither prenatal nor postnatal maternal depressive symptoms independently predicted neither the frontal EEG activity nor functional connectivity in 6- and 18-month infants. However, increasing maternal depressive symptoms from the prenatal to postnatal period predicted greater right frontal activity and relative right frontal asymmetry amongst 6-month infants but these finding were not observed amongst 18-month infants after adjusted for post-conceptual age on the EEG visit day. Subsequently increasing maternal depressive symptoms from the prenatal to postnatal period predicted lower right frontal connectivity within 18-month infants but not among 6-month infants after controlling for post-conceptual age on the EEG visit day. These findings were observed in the full sample and the female sample but not in the male sample. Moreover, both prenatal and early postnatal maternal depressive symptoms independently predicted children's externalizing and internalizing behaviors at 24 months of age. This suggests that the altered frontal functional connectivity in infants born to mothers whose depressive symptomatology increases in the early postnatal period compared to that during pregnancy may reflect a neural basis for the familial transmission of phenotypes associated with mood disorders, particularly in girls.

Forklift-Related Crush Injuries of the Foot and Ankle.

BACKGROUND: Forklift-related crush injuries of the foot and ankle are relatively common in cities with shipping and construction industries. There is a paucity of literature on the incidence and sequelae of such injuries. We aimed to describe the incidence, patterns of injuries, sequelae, and morbidity associated with this type of injury. METHODS: A retrospective review of all patients with forklift-related crush injuries of the foot and ankle for 4 years was conducted. Patients' demographics, mechanisms and patterns of injury, fracture type, compartment syndrome, number of reconstructive operations, operative details, length of hospital stay, medical leave, repeat evaluation in emergency room, and complications were recorded and analyzed. RESULTS: There were 113 (2.17%) patients with forklift-related crush injuries out of 5209 patients seen in our institution for injuries of the foot and ankle. Crush injury from the wheels of the forklift truck was the most common mechanism at 71 (62.8%) patients. The forefoot was the most commonly injured region, followed by the midfoot, hindfoot, and ankle, with almost one-third (28.3%) of the patients having multiple injuries to the foot. Nine (8%) had open fractures, while 5 (4.4%) had compartment syndromes. Forty (35.4%) patients required hospitalization, and 35 (87.5%) of those hospitalized required operative intervention. Those who had surgery were more likely to have complications compared with those who did not require operative intervention (16 [45.7%] of 35 patients vs 7 [9%] of 78 patients; P < .05) and more likely to require longer medical leave (mean, 183 vs 30 days, P < .05). CONCLUSION: Forklift-related crush injuries of the foot and ankle are increasingly common in industrialized cities. The forefoot is commonly affected with involvement of multiple regions. Up to one-third of affected patients required hospitalization and multiple operative interventions resulting in loss of productivity, income, and significant morbidity. The possibility of residual disabilities must be clearly defined to the patients and their employers to manage potential workplace limitations and long-term expectations. LEVEL OF EVIDENCE: Level IV retrospective case series.