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JAMA Surgery Jun 2024According to the Centers for Disease Control and Prevention and governing bodies within the American College of Surgeons, the administration of antibiotics as...
IMPORTANCE
According to the Centers for Disease Control and Prevention and governing bodies within the American College of Surgeons, the administration of antibiotics as prophylaxis against infection prior to a planned elective procedure is, with rare exception, routinely recommended. The goal of "getting to zero" infections remains a high priority for policymakers, practitioners, and certainly for patients.
OBSERVATIONS
Despite the many advances in surgical technique, skin decontamination, sterile procedure, and enhanced recovery programs, surgical site infections continue to adversely affect procedures as diverse as dental implant surgery, joint arthroplasty, and major abdominal surgery. Although surgical site infection rates are at historically low levels, progress has stalled in recent reporting periods and such infections remain disabling, costly, and occasionally lethal. Stakeholders in the field, including surgeons, infectious diseases specialists, and industry, advocate for strategies emphasizing greater levels of intraoperative sterility or broader-spectrum antibiotic coverage as the most appropriate path forward.
CONCLUSIONS AND RELEVANCE
The current emphasis on ever-increasing levels of intraoperative sterility and extended-spectrum antibiotic use are not sustainable long-term solutions. Continuing to escalate these approaches may contribute to unintended consequences including antimicrobial resistance. Principles of antimicrobial stewardship and microbiome sciences can be applied to inform a more effective and sustainable approach to infection prevention in the field of surgery.
PubMed: 38922606
DOI: 10.1001/jamasurg.2024.0429 -
JAMA Dermatology Jun 2024Access to timely dermatologic care remains a challenge, especially for patients with new skin lesions. Assessing the efficiency of new triage pathways may assist in...
IMPORTANCE
Access to timely dermatologic care remains a challenge, especially for patients with new skin lesions. Assessing the efficiency of new triage pathways may assist in better resource allocation and shorter time to care.
OBJECTIVE
To evaluate whether a rule-based triage system was associated with better skin cancer risk stratification of patients and reduced wait times.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective quality improvement cohort study of patients referred to Stanford University dermatology clinics was conducted between November 2017 and January 2023. A rules-based triage system based on a priori-determined high-risk lesion characteristics was implemented.
EXPOSURES
Referral reasons and risk factors of patients provided by their primary care physicians.
MAIN OUTCOMES AND MEASURES
Biopsy results of patients (diagnosis of any skin cancer and melanoma) at their visit or within 6 months after the visit. Regression models were used to assess the association between risk factors at referral and (1) biopsy outcomes and (2) time to first visit, adjusting for sociodemographic factors.
RESULTS
Among 37 478 patients (mean [SD] age, 54 (18) years; 21 292 women [57%]), the rates of aggregate biopsy, malignant biopsy specimens, and melanoma were comparable across patients seen after (n = 12 302) and before (n = 25 176) the implementation of the new triage pathway. Patients seen through the lesion pathway had a higher risk of having malignant biopsy results (adjusted risk ratio [aRR], 1.6; 95% CI, 1.4-1.9) and melanoma (aRR, 2.0; 95% CI, 1.2-3.2) than those not seen through the pathway. Lesions that were concerning to referring clinicians for skin cancer were associated with an increased risk of skin cancer (all skin cancer: aRR, 2.8; 95% CI, 2.2-3.5; melanoma: aRR, 2.02; 95% CI, 1.1-3.7). Patients in the 3 high-risk lesion groups were seen faster in the new triage pathway (mean reduction, 26 days; 95% CI, 18-34 days).
CONCLUSIONS AND RELEVANCE
In this study, a new automated, rules-based referral pathway was implemented that expedited care for patients with high-risk skin cancer. This reform may have contributed to improving patient stratification, reducing the time from referral to first encounter, and maintaining accuracy in identifying malignant lesions. The findings highlight the potential to optimize clinical resource allocation by better risk stratification of referred patients.
PubMed: 38922597
DOI: 10.1001/jamadermatol.2024.1832 -
Journal of Fungi (Basel, Switzerland) May 2024The skin mycobiota plays a significant role in infection risk, pathogen transmission, and personalized medicine approaches in intensive care settings. This prospective...
The skin mycobiota plays a significant role in infection risk, pathogen transmission, and personalized medicine approaches in intensive care settings. This prospective multicenter study aimed to enhance our understanding of intensive care units' (ICUs') colonization dynamics, identify modifiable risk factors, and assess their impact on survival risk. Specimens were taken from 675, 203, and 110 patients at the admission (D1), 5th (D5), and 8th (D8) days of ICU stay, respectively. The patient's demographic and clinical data were collected. isolates were identified by conventional culture-based microbiology combined with molecular approaches. Overall, colonization was 184/675 (27.3%), 87/203 (42.8%), and 58/110 (52.7%) on D1, D5, and D8, respectively. colonization dynamics were significantly associated with ICU type (odds ratio (OR) = 2.03, 95% CI 1.22-3.39, = 0.007), respiratory infection (OR = 1.74, 95% CI 1.17-2.58, = 0.006), hemodialysis (OR = 2.19, 95% CI 1.17-4.10, = 0.014), COVID-19 (OR = 0.37, 95% CI 0.14-0.99, = 0.048), and with a poor 3-month outcome ( = 0.008). Skin spp. colonization can be an early warning tool to generate valuable insights into the epidemiology, risk factors, and survival rates of critically ill patients, and should be considered for epidemiological surveillance.
PubMed: 38921364
DOI: 10.3390/jof10060378 -
Healthcare (Basel, Switzerland) Jun 2024The prevalence of dermatological conditions in primary care, coupled with challenges such as dermatologist shortages and rising consultation costs, highlights the need... (Review)
Review
The prevalence of dermatological conditions in primary care, coupled with challenges such as dermatologist shortages and rising consultation costs, highlights the need for innovative solutions. Artificial intelligence (AI) holds promise for improving the diagnostic analysis of skin lesion images, potentially enhancing patient care in primary settings. This systematic review following PRISMA guidelines examined primary studies (2012-2022) assessing AI algorithms' diagnostic accuracy for skin diseases in primary care. Studies were screened for eligibility based on their availability in the English language and exclusion criteria, with risk of bias evaluated using QUADAS-2. PubMed, Scopus, and Web of Science were searched. Fifteen studies (2019-2022), primarily from Europe and the USA, focusing on diagnostic accuracy were included. Sensitivity ranged from 58% to 96.1%, with accuracies varying from 0.41 to 0.93. AI applications encompassed triage and diagnostic support across diverse skin conditions in primary care settings, involving both patients and primary care professionals. While AI demonstrates potential for enhancing the accuracy of skin disease diagnostics in primary care, further research is imperative to address study heterogeneity and ensure algorithm reliability across diverse populations. Future investigations should prioritise robust dataset development and consider representative patient samples. Overall, AI may improve dermatological diagnosis in primary care, but careful consideration of algorithm limitations and implementation strategies is required.
PubMed: 38921305
DOI: 10.3390/healthcare12121192 -
Current Issues in Molecular Biology May 2024Skin aging is an unavoidable natural phenomenon caused by intrinsic and extrinsic factors. In modern society, the pursuit of a wrinkle-free and aesthetically appealing...
Skin aging is an unavoidable natural phenomenon caused by intrinsic and extrinsic factors. In modern society, the pursuit of a wrinkle-free and aesthetically appealing face has gained considerable prominence. Numerous studies have aimed at mitigating the appearance of facial wrinkles. Antiaging research focused on regulating the function of mitochondria, the main reactive oxygen species-generating organelles, has been extensively conducted. In this study, we investigated the correlation between facial wrinkles and the expression of , considering the association of this gene with mitochondrial function, to identify its potential as a target for exploring antiaging cosmetic materials. We elucidated the role of in the skin and identified five bioactive materials that modulated its expression. The effectiveness of these materials was verified through in vitro experiments on human dermal fibroblasts. We prepared cosmetic formulations incorporating the five materials and confirmed their ability to enhance dermal collagen in three-dimensional skin models and reduce facial wrinkles under the eyes and nasolabial fold areas in human subjects. The study findings have significant implications for developing novel antiaging cosmetic formulations by reinforcing mitochondrial functions.
PubMed: 38920974
DOI: 10.3390/cimb46060302 -
Journal of Anaesthesiology, Clinical... 2024To compare ultra-sonographic dimensions of acoustic target window of the spine in the participants at four different sitting positions namely cross leg sitting (CLP),...
BACKGROUND AND AIMS
To compare ultra-sonographic dimensions of acoustic target window of the spine in the participants at four different sitting positions namely cross leg sitting (CLP), hamstring stretch (HSP), classical sitting (CSP) and riders sitting position (RSP). The primary objective of this study was to measure the neuraxial acoustic target window (defined as interlaminar distance between L3-L4 lamina). The secondary objective was to compare ultra-sonographic measurements of the depth of ligamentum flavum from the skin, and to compare the diameter of intrathecal space and comfort score in the four different sitting positions.
MATERIAL AND METHODS
This study is a prospective observational study. Eighty participants were included and positioned in four different sitting positions to perform an ultra-sonographic scan and measure various parameters of the acoustic neuraxial window. The interlaminar distance, the distance of skin from the ligamentum flavum, and the diameter of the spinal canal or intrathecal space was measured in the L3-L4 intervertebral space in different positions.
RESULTS
The mean value of interlaminar distance among four sitting positions was ranging from 1.40 cm to 1.44 cm ( value 0.725.) The distance of ligamentum flavum from skin and diameter of intrathecal space was also comparable in all the groups. The comfort score in CSP was significantly better when compared to other groups with a median score of 4 ( value < 0.001).
CONCLUSIONS
There is no statistically significant difference in interlaminar distance in various sitting positions. All four positions are equally effective and can be used as an alternative to spinal/epidural intervention, but the CSP came out to be the most comfortable and more emphasis should be given to the comfort as it increases the chance of success rate of the procedure.
PubMed: 38919435
DOI: 10.4103/joacp.joacp_450_22 -
Journal of Anaesthesiology, Clinical... 2024Thoracic epidural insertion has high failure rates in the mid-thoracic region due to steep angulation of oblique bending of spinous processes. The preferred skin...
BACKGROUND AND AIMS
Thoracic epidural insertion has high failure rates in the mid-thoracic region due to steep angulation of oblique bending of spinous processes. The preferred skin puncture point for epidural needle insertion in the paramedian sagittal plane with respect to the superior/inferior tip of spinous process or inter-spinous cleft in the mid-thoracic region (T5-8) is not standard. The primary objective of this prospective observational study was to find the skin puncture point which had the best success rate for a successful epidural catheterization. Secondary objectives were to study the number of attempts and passes required to locate epidural space, incidence of failed epidural, and its relationship with patient characteristics and demographics.
MATERIAL AND METHODS
After informed consent, 155 patients planned for general anesthesia with epidural analgesia in the mid-thoracic region were included in the trial. Patient demographics, the details of epidural attempts with respect to anatomical landmarks, distance from the midline, and number of passes in each attempt were noted. Epidural catheterization was considered successful after demonstrating dermatomal band of sensory blockade.
RESULTS
The success rate at different skin puncture sites was not statistically significant ( = 0.58). We found a failure rate of 12.9%. Failed epidural catheterization was significantly high in the age group >56 years ( = 62 and = 0.007).
CONCLUSION
In our study, none of the skin puncture points had a significant association with successful epidural insertion in mid-thoracic segments using a para-median approach.
PubMed: 38919420
DOI: 10.4103/joacp.joacp_448_22 -
Annals of Vascular Diseases Jun 2024Distal bypass surgery's effect on tissue blood pressure beyond a focal angiosome remains debated. This study assessed tissue blood pressure in both direct...
Distal bypass surgery's effect on tissue blood pressure beyond a focal angiosome remains debated. This study assessed tissue blood pressure in both direct revascularized angiosome (DRA) and indirect revascularized angiosome (IRA) after bypass surgery, utilizing repeated skin perfusion pressure (SPP) measurements. Twenty-nine limbs in 27 chronic limb-threatening ischemia (CLTI) patients (22 males and five females, age: 70.2 ± 9.3 years) who received distal bypass surgery were enrolled. SPP measurements were conducted for the DRA and IRA at 10 time intervals, encompassing both preoperative and postoperative periods of every 3-5 days until 30 days. In total, 486 SPP measurements were collected from 58 measurement sites, and the transition of the SPP at the DRA was 35.4-62.5-59.5-70.2-58.2-62.2-63.1-63.6-63.8-73.4 mmHg and IRA was 29.4-53.4-53.7-58.8-51.3-63.1-47.9-62.1-57.6-61.0 mmHg. No significant differences were observed between SPP at the DRA and IRA. Fifteen wounds on the DRA (63%) and five on the IRA (100%) healed. Distal bypass improves SPP in both direct and IRAs of CLTI patients. These data indicated distal bypass improves tissue blood flow at entire foot regardless of angiosomes.
PubMed: 38919324
DOI: 10.3400/avd.oa.23-00105 -
Annals of Vascular Diseases Jun 2024Lymphedema is caused by dysfunction of the lymphatic system. It is divided into primary edema with no apparent cause and secondary edema with an exogenous cause. The... (Review)
Review
Lymphedema is caused by dysfunction of the lymphatic system. It is divided into primary edema with no apparent cause and secondary edema with an exogenous cause. The main symptoms are edema and heaviness, skin changes such as skin hardening, lymphocysts, lymphorrhoea, papillomas, and recurrent cellulitis. They are often irreversible and progressive, thus greatly reducing quality of life of the patients. Diagnosis is made by image examinations that can evaluate lymphatic flow and functions such as lymphoscintigraphy and indocyanine green fluorescence lymphangiography. Linear pattern and dermal backflow are the main findings. Conservative treatment consists of four components: compression therapy with elastic garments, exercise therapy, manual lymphatic drainage, and skin care, which is called complex physical therapy (CPT). Although CPT has become the gold standard of treatment, with evidence of efficacy reported in terms of volume reduction, maintenance, and prevention of cellulitis, it is a symptomatic treatment and does not improve impaired lymphatic flow. On the other hand, surgical treatment, such as lymphaticovenous anastomosis and vascularized lymph node transplantation, can create new lymphatic flow and improve lymphatic dysfunctions. Although these techniques are expected to be effective in volume reduction, cellulitis prevention, and improving quality of life, there is a need for more studies with a higher level of evidence in the future. In Japan, lymphedema is treated with a combination of conservative and surgical therapies, but lymphedema is intractable and few cases are completely cured. Therefore, how to improve the outcome of treatment is an important issue to be addressed in the future. (This is a translation of Jpn J Vasc Surg 2023; 32: 141-146.).
PubMed: 38919315
DOI: 10.3400/avd.ra.24-00011 -
Annali Italiani Di Chirurgia Nov 2023Pancreatic neuroendocrine tumors (PNETs) are rare and accounting for less than 5% of all pancreatic neoplasms. Their management depends on dimension of the lesion, main... (Review)
Review
BACKGROUND
Pancreatic neuroendocrine tumors (PNETs) are rare and accounting for less than 5% of all pancreatic neoplasms. Their management depends on dimension of the lesion, main pancreatic duct (MPD) caliber, tumor malignancy features and evolutive potential.
CASE REPORT
Incidental finding of a lesion 1.2 cm wide of the pancreatic body, after contrast enhanced total body CT, in a 71 years old obese Caucasian male (BMI>25), during follow-up for cutaneous melanoma. The lesion was confirmed by MRI and 68-Ga pancreatic scintigraphy. EUS showed a second hypoecogenic and hypovascularized lesion compatible with pancreatic tail PNET. After FNB, Ki-67 was below 3%.
DISCUSSION
68-Gallium PET-CT was the preferred technique for the staging of the neuroendocrine neoplasm, for treatment planning, for the localization of the pancreatic lesion, excluding the presence of unknown extra-pancreatic lesions. EUS-FNB is indicated in patient with suspicion of PNET, although further investigation is needed to include it as a routine diagnostic examination.
CONCLUSION
Surgery is mandatory in case of PNETs larger than 2 cm, with MPD dilation, Ki-67>20% and compression symptoms.
Topics: Humans; Male; Pancreatic Neoplasms; Aged; Incidental Findings; Neuroendocrine Tumors; Skin Neoplasms; Melanoma; Positron Emission Tomography Computed Tomography
PubMed: 38919024
DOI: No ID Found