Outcomes of Upper Lip Mohs Surgery Repairs Using Standardized Scar Scales With Particular Emphasis on Vermillion Border Involvement.

BACKGROUND: The lips are a common location for skin cancer, and thus, a common site for Mohs micrographic surgery (MMS). As an important cosmetic and functional facial unit, MMS defects and reconstruction can affect patient perception on functional and aesthetic outcomes. OBJECTIVE: The objective of this study was to compare aesthetic and functional outcomes after upper lip MMS between patients with vermillion sparing repairs (VSR) versus vermillion crossing repairs (VCR). MATERIALS AND METHODS: Patients from a single institution from 2018 to 2022 undergoing MMS of the upper lip with linear or select flap repairs were included. Patients were assessed at a minimum of 6-week follow-up for self-assessment of functional and cosmetic outcomes, as well as physician assessment of scar cosmesis using validated Patient and Observed Scar Assessment Scale and Scar Cosmesis Assessment and Rating scale. The results were compared between VSR and VCR groups. RESULTS: Forty-five patients were included in this study. No significant difference between patient assessment of functional and cosmetic outcome was identified between VSR and VCR. CONCLUSION: Patient satisfaction with lip reconstruction can be high. Crossing the vermillion border does not affect patient assessment of aesthetic and functional results and should be considered if needed to optimize reconstructive outcomes.

Comparison of infection control practices in a Dutch and US hospital using the infection risk scan (IRIS) method.

BACKGROUND: The infection risk scan (IRIS) is a tool to measure the quality of infection control (IC) and antimicrobial use in a standardized way. We describe the feasilibility of the IRIS in a Dutch hospital (the Netherlands, NL) and a hospital in the United States (US). METHODS: Cross-sectional measurements were performed. Variables included a hand hygiene indicator, environmental contamination, IC preconditions, personal hygiene of health care workers, use of indwelling medical devices, and use of antimicrobials. RESULTS: IRIS was performed in 2 wards in a US hospital and 4 wards in a Dutch hospital. Unjustified use of medical devices: none in the US hospital, 2.2% in the Dutch hospital; inappropriate use of antibiotics: 11.7% (US), 19% (NL); items considered not clean: 10% (US); 36% (NL); shortcomings preconditions: 6 of 20 (US), 6 of 40 (NL); health care workers with rings, watches, or long sleeves: 34 of 43 (US), none in the NL hospital; and hand hygiene actions per patient/day: 41 (US) and 10 (NL). US data judged against the Dutch guidelines and vice versa revealed remarkable differences. CONCLUSIONS: We showed the feasibility of using the IRIS in a US hospital. The method provided insight in IC local performance. This method could be the first step to standardize the measurement of the quality of IC and antimicrobial use. However, if the IRIS is used for benchmarking between hospitals in different regions, this should be done in the context of regional guidelines and policies.

Prevention of hospital-acquired respiratory viral infections: Assessment of a multimodal intervention program.

A multimodal program focused on preventing nosocomial respiratory viral infections. Definite cases per 1,000 discharges increased 1.3-fold in hospital units screening visitors for respiratory viral symptoms during the 2017-2018 respiratory virus season but not during the 2016-2017 season. Definite cases per 1,000 discharges increased 3.1-fold in hospital units that did not screen visitors either season.

Incontinentia Pigmenti Coxsackium.

Late recurrences of first-stage inflammatory vesiculobullous lesions of incontinentia pigmenti (IP) are uncommon but have been reported to occur in the setting of infections, fevers, and vaccinations. This phenomenon has not been described in the setting of atypical hand, foot, and mouth disease (HFMD). In addition, atypical HFMD often has a predilection for areas of previous inflammation or trauma, such as areas of atopic dermatitis (eczema coxsackium). We present a case of incontinentia pigmenti coxsackium in which a coxsackievirus infection triggered reactivation of IP and cutaneous viral lesions were concentrated in areas of IP.

Follicular Mucinosis in a Male Adolescent with a History of Acute Myelogenous Leukemia and Graft-versus-Host Disease.

Although many cases of follicular mucinosis are idiopathic, numerous others are associated with mycosis fungoides or, rarely, other neoplastic or inflammatory disorders. There are only three reported cases, all in adults, of follicular mucinosis arising in association with acute myelogenous leukemia, two of which involved mycosis fungoides-associated follicular mucinosis, including one case in which the patient had a preceding bone marrow transplant. We present the first reported case of follicular mucinosis arising in an adolescent with acute myelogenous leukemia and acute graft-versus-host disease after an allogeneic bone marrow transplantation.

Coral contact dermatitis.

Corals can elicit both toxic and allergic reactions upon contact with the skin. Clinical presentations vary depending on whether the reaction is acute, delayed, or chronic. Literature concerning cutaneous reactions to corals and other Cnidarians is scarce. Herein we report a case of delayed contact hypersensitivity reaction to coral and review the clinical and histopathological features of coral contact dermatitis.

Localized chronic fibrosing vasculitis in a tattoo: a unique adverse tattoo reaction.

Decorative tattoos are associated with a variety of adverse cutaneous reactions. We describe a unique fibrosing vasculitic reaction to red tattoo ink. The histopathology was similar to that in localized chronic fibrosing vasculitis (LCFV), but sharply limited to sites of red tattoo ink injection and associated with florid verrucoid epidermal hyperplasia. LCFV has been described in a broad variety of slowly progressive disorders with a firm consistency such as erythema elevatum diutinum, plasma cell granuloma, granuloma faciale, and IgG4-associated sclerosing diseases. It has been hypothesized that LCFV is the result of maladaptive immune reaction with failure to clear the causative antigen. To the best of our knowledge, this is the first case of LCFV associated with tattoo. We speculate on the implications our case holds for the pathogenesis of LCFV.

A slowly enlarging mass on the finger.

An otherwise healthy 71-year-old woman presented with an asymptomatic mass on her right 4th finger that had been slowly enlarging over the past 2 years. On physical examination, there was a tan-pink, freely mobile, rubbery 9-mm papule with a central keratotic plug located over the extensor aspect of the proximal interphalangeal joint of the right 4th finger. A 3-mm punch biopsy of the lesion was performed. Histopathologic findings were consistent with a diagnosis of aggressive digital papillary adenocarcinoma (ADPAca), an adnexal tumor with high metastatic potential that is unfortunately commonly misdiagnosed owing to its rarity and nondescript appearance. Aggressive surgical treatment including radical excision or digital amputation with or without sentinel lymph node biopsy is advocated in the treatment of ADPAca.

Factors associated with hand hygiene compliance at a tertiary care teaching hospital.

OBJECTIVE: To identify factors associated with hand hygiene compliance during a multiyear period of intervention. DESIGN: Observational study. SETTING: A 719-bed tertiary care teaching hospital. PARTICIPANTS: Nursing, physician, technical, and support staff. METHODS: Light-duty staff performed hand hygiene observations during the period July 2008-December 2012. Infection control implemented hospital-wide hand hygiene initiatives, including education modules; posters and table tents; feedback to units, medical directors and the executive board; and an increased number of automated alcohol hand hygiene product dispensers. RESULTS: There were 161,526 unique observations; overall compliance was 83%. Significant differences in compliance were observed between physician staff (78%) and support staff (69%) compared with nursing staff (84%). Pediatric units (84%) and intensive care units (84%) had higher compliance than did medical (82%) and surgical units (81%). These findings persisted in the controlled multivariate model for noncompliance. Additional factors found to be significant in the model included greater compliance when healthcare workers were leaving patient rooms, when the patient was under contact precautions, and during the evening shift. The overall rate of compliance increased from 60% in the first year of observation to a peak of 96% in the fourth year, and it decreased to 89% in the final year, with significant improvements occurring in each of the 4 professional categories. CONCLUSIONS: A multipronged hand hygiene initiative is effective in increasing compliance rates among all categories of hospital workers. We identified a variety of factors associated with increased compliance. Additionally, we note the importance of continuous interventions in maintaining high compliance rates.

Reducing Clostridium difficile incidence, colectomies, and mortality in the hospital setting: a successful multidisciplinary approach.

BACKGROUND: Health care associated Clostridium difficile infections are a major cause of morbidity and mortality in hospitals. In the United States, from 2000 through 2009, discharge diagnoses from hospitals in the United States that included C. difficile increased from 139,000 to 336,600, and the yearly national excess hospital cost associated with hospital-onset C. difficile is estimated to be upwards of $1.3 billion. METHODS: A hospitalwide, multidisciplinary approach was undertaken at Rhode Island Hospital (Providence), a tertiary care hospital. The hospital plan entailed six interventions: (1) develop a C. difficile hospital infection control plan based on a risk assessment; (2) monitor hospitalwide morbidity and mortality associated with C. difficile infection; (3) improve sensitivity of C. difficile toxin detection in stool specimens using a polymerase chain reaction-based nucleic acid amplification assay; (4) enhance environmental cleaning of patient rooms and equipment; (5) develop a C. difficile infection treatment plan; and (6) conduct other interventions. The incidence of health care-associated C. difficile infection was assessed from January 2006 through the third quarter of 2012; the number of colectomies and mortality associated with C. difficile infection were determined from January 2005 through the third quarter of 2012. RESULTS: The incidence of health care-associated C. difficile infection decreased from a peak of 12.2/1,000 discharges during the second quarter of 2006 to 3.6/1,000 discharges during the third quarter of 2012. The yearly mortality in patients with health care-associated C. difficile infection was reduced from a peak of 52 in 2006 to 19 in 2011, with 13 such cases in the first three quarters of 2012. CONCLUSIONS: A hospitalwide multidisciplinary approach can reduce health care-associated C. difficile infection morbidity and mortality.

Update on nail cosmetics.

Nail cosmetics are used by millions of people worldwide who desire smooth, lustrous nails. The nail cosmetic industry continues to expand to meet increasing consumer demand. In 2011 alone, consumers spent $6.6 billion on nail salon services. Although nail cosmetics are relatively safe, poor application techniques can promote disease, deformity, and allergic and irritant contact dermatitis. The foundation for managing nail cosmetic problems is prevention through education. Familiarity with the procedures and materials used in the nail cosmetic industry is necessary in order to recommend safe nail care strategies.

Melanonychia.

Melanonychia, or melanin-derived brown-to-black nail pigmentation, is a diagnostic challenge for clinicians. The most serious disease of the nail unit, melanoma, primarily presents with melanonychia. However, melanonychia most often occurs as a result of benign etiologies such as nail matrix melanocytic activation, nail matrix melanocytic hyperplasia, and nail invasion by melanin-producing pathogens. Regrettably, patients with nail apparatus melanoma are often initially misdiagnosed, and due to diagnostic delays of an average of 2 years, melanoma of the nail unit carries a poor prognosis. Having a thorough knowledge of the various causes of melanonychia and using a systematic approach when evaluating brown-to-black nail pigmentation may help prevent misdiagnosis and thereby improve prognosis.

Peripheral venous catheter-related Staphylococcus aureus bacteremia.

OBJECTIVE: Better understand the incidence, risk factors, and outcomes of peripheral venous catheter (PVC)-related Staphylococcus aureus bacteremia. DESIGN: Retrospective study of PVC-related S. aureus bacteremias in adult patients from July 2005 through March 2008. A point-prevalence survey was performed January 9, 2008, on adult inpatients to determine PVC utilization; patients with a PVC served as a cohort to assess risk factors for PVC-related S. aureus bacteremia. SETTING: Tertiary care teaching hospital. RESULTS: Twenty-four (18 definite and 6 probable) PVC-related S. aureus bacteremias were identified (estimated incidence density, 0.07 per 1,000 catheter-days), with a median duration of catheterization of 3 days (interquartile range, 2-6). Patients with PVC-related S. aureus bacteremia were significantly more likely to have a PVC in the antecubital fossa (odds ratio [OR], 6.5), a PVC placed in the emergency department (OR, 6.0), or a PVC placed at an outside hospital (P = .005), with a longer duration of catheterization (P < .001). These PVCs were significantly less likely to have been inserted in the hand (OR, 0.23) or placed on an inpatient medical unit (OR, 0.17). Mean duration of antibiotic treatment was 19 days (95% confidence interval, 15-23 days); 42% (10/24) of cases encountered complications. We estimate that there may be as many as 10,028 PVC-related S. aureus bacteremias yearly in US adult hospitalized inpatients. CONCLUSION: PVC-related S. aureus bacteremia is an underrecognized complication. PVCs inserted in the emergency department or at outside institutions, PVCs placed in the antecubital fossa, and those with prolonged dwell times are associated with such infections.

Impact of chlorhexidine bathing on hospital-acquired infections among general medical patients.

BACKGROUND: A paucity of data exists regarding the effectiveness of daily chlorhexidine gluconate (CHG) bathing in non-intensive care unit (ICU) settings. OBJECTIVE: To evaluate the effectiveness of daily CHG bathing in a non-ICU setting to reduce methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enteroccocus (VRE) hospital-acquired infections (HAIs), compared with daily bathing with soap and water. DESIGN: Quasi-experimental study design; the primary outcome was the composite incidence of MRSA and VRE HAIs. Clostridium difficile HAI incidence was measured as a nonequivalent dependent variable with which to assess potential confounders. SETTING: Four general medicine units, with a total of 94 beds, at a 719-bed academic tertiary-care facility in Providence, Rhode Island. PATIENTS: A total of 7,102 and 7,699 adult patients were admitted to the medical service in the control and intervention groups, respectively. Patients admitted from January 1 through December 31, 2008, were bathed daily with soap and water (control group), and those admitted from February 1, 2009, through March 31, 2010, were bathed daily with CHG-impregnated cloths (intervention group). RESULTS: Daily bathing with CHG was associated with a 64% reduced risk of developing the primary outcome, namely, the composite incidence of MRSA and VRE HAIs (hazard ratio, 0.36 [95% CI, 0.2-0.8]; P = .01). There was no change in the incidence of C. difficile HAIs (P = .6). Colonization with MRSA was associated with an increased risk of developing a MRSA HAI (hazard ratio, 8 [95% CI, 3-19]; P < .001). CONCLUSION: Daily CHG bathing was associated with a reduced HAI risk, using a composite endpoint of MRSA and VRE HAIs, in a general medical inpatient population.

A novel technique for identifying opportunities to improve environmental hygiene in the operating room.

Environmental cleaning and disinfection is essential for optimizing safe patient care in the OR; however, perioperative staff members have not had an easy-to-use, objective method for determining whether high-touch, potentially contaminated surfaces have been cleaned during terminal room cleaning. To address this issue, members of the Healthcare Environmental Hygiene Study Group used a transparent, removable, environmentally stable disclosing agent and handheld ultraviolet light to determine whether potentially contaminated surfaces had been contacted by a wet disinfection cleaning cloth during terminal cleaning of ORs. Results from the project showed that 237 of 946 targeted surfaces (25%) had the disclosing agent removed (ie, were cleaned). The use of the disclosing agent for staff education and process monitoring has led to significant improvements in the disinfection cleaning process.

A cluster of community-acquired methicillin-resistant Staphylococcus aureus infections in hospital security guards.

We investigated a cluster of methicillin-resistant Staphylococcus aureus soft-tissue infections in 5 security guards employed in a hospital emergency department. An epidemiologic investigation and molecular subtyping of isolates revealed that the source was a patient and that a community-acquired methicillin-resistant S. aureus strain (USA-300) was transmitted to healthcare workers through physical contact.

Potential economic impact of hospital-acquired infections in uninsured patients: a preliminary investigation.

We studied uninsured patients admitted to Rhode Island Hospital from January 1 through June 30, 2005, and from January 1 through June 30, 2006. The mean total hospital charge for an uninsured patient with a hospital-acquired infection was $18,487; for those without such an infection, it was $4,951 (P < .001). Multivariable linear regression revealed that a hospital-acquired infection accounted for 11.8 excess hospital days (P = .001). Length of stay was the only independent variable associated with total excess hospital charges.