Mohs micrographic surgery in immunosuppressed vs immunocompetent patients: Results of a prospective nationwide cohort study (REGESMOHS, Spanish registry of Mohs surgery).

BACKGROUND: Immunosuppressed (IS) patients, particularly solid organ transplant recipients and those on immunosuppressive therapy, face a higher incidence and recurrence of nonmelanoma skin cancers (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Mohs micrographic surgery (MMS) is the preferred treatment for high-risk NMSC due to its high cure rate and margin examination capabilities. However, IS patients may experience more complications, such as surgical site infections, and a greater risk of recurrence, making their outcomes a subject of interest. OBJECTIVES: This study aimed to compare IS and immunocompetent (IC) patients undergoing MMS for NMSC in terms of baseline characteristics, intra- and post-surgical complications, and postoperative recurrence rates. METHODS: The study utilized data from the REGESMOHS registry, a 7-year prospective cohort study in Spain. It included 5226 patients, categorizing them into IC (5069) and IS (157) groups. IS patients included solid organ transplant recipients, those on immunosuppressive treatments, individuals with haematological tumours and HIV-positive patients. Patient data, tumour characteristics, surgical details and outcomes were collected and analysed. RESULTS: IS patients demonstrated a higher proportion of SCC, multiple synchronous tumours and tumours invading deeper structures. Complex closures, unfinished MMS and more surgical sections were observed in the IS group. Although intra-operative morbidity was higher among IS patients, this difference became non-significant when adjusted for other variables such as year of surgery, antiplatelet/anticoagulant treatment or type of closure. Importantly, IS patients had a substantially higher recurrence rate (IRR 2.79) compared to IC patients. CONCLUSIONS: This study suggests that IS patients may be at a higher risk of development of AE such as bleeding or tumour necrosis and are at a higher risk of tumour recurrence. Close follow-up and consideration of the specific characteristics of NMSC in IS patients are crucial. Further research with extended follow-up is needed to better understand the long-term outcomes for this patient group.

Development and validation of a model to predict complex Mohs micrographic surgery in clinical practice: REGESMOSH scale.

INTRODUCTION: There is still a need to develop a simple algorithm to identify patients likely to need complex Mohs micrographic surgery (MMS) and optimize MMS schedule. The main objectives of this study are to identify factors associated with a complex MMS and develop a predictor model of the number of stages needed in surgery and the need for a complex closure. MATERIALS AND METHODS: A nationwide prospective cohort study (REGESMOHS, the Spanish Mohs surgery registry) was conducted including all patients with a histological diagnosis of basal cell carcinoma (BCC). Factors related to three or more stages and a complex closure (that needing a flap and/or a graft) were explored and predictive models were constructed and validated to construct the REGESMOSH scale. RESULTS: A total of 5226 patients that underwent MMS were included in the REGESMOHS registry, with 4402 (84%) having a histological diagnosis of BCC. A total of 3689 (88.9%) surgeries only needed one or two stages and 460 (11.1%) required three or more stages. A model to predict the need for three or more stages included tumour dimension, immunosuppression, recurrence, location in risk areas, histological aggressiveness and previous surgery. Regarding the closure type, 1616 (38.8%) surgeries were closed using a non-complex closure technique and 2552 (61.2%) needed a complex closure. A model to predict the need for a complex closure included histological aggressiveness, evolution time, patient age, maximum tumour dimension and location. CONCLUSION: We present a model to predict MMS needing ≥3 stages and a complex closure based on epidemiological and clinical data validated in a large population (with real practice variability) including different centres that could be easily implemented in clinical practice. This model could be used to optimize surgery schedule and properly inform patients about the surgery duration.

[Prevalence of burnout in healthcare workers during the COVID-19 pandemic and associated factors. A cross-sectional study]. / Prevalencia de síndrome de burnout en personal de salud durante la pandemia de COVID-19 y factores asociados. Estudio de corte transversal.

The COVID-19 pandemic generated an overload of the health system and mental, emotional, and physical exhaustion of workers. Previous studies have reported elevated levels of burnout syndrome in healthcare workers. The objective of the study was to estimate the prevalence and associated factors of burnout syndrome in healthcare workers. A cross-sectional study was conducted through the administration of an email survey during the second wave of COVID-19 cases. Burnout was evaluated using the Maslach Burnout Inventory questionnaire. The prevalence of burnout was estimated and the associated factors were analyzed using multivariate logistic regression analysis. The 84% of the participants completed the survey (N = 133), 106 were physicians (80%), 11 administrators (8%), 9 respiratory physiologists (7%), and 7 nurses (5%). 62% were women. The prevalence of burnout was 38% (95% CI 30-47%) and it was different according to the occupation (p = < 0.001). Physicians and respiratory kinesiologists presented the highest values with a prevalence of 40% and 89% respectively. In the multivariate analysis, the variables that were independently associated with the burnout syndrome were: being a physician (OR = 8.9; 95% CI: 1.1-71; p: 0.041) and being a respiratory kinesiologist (OR = 137.5; 95% CI: 2-262; p 0.001). The prevalence of burnout syndrome in healthcare workers during the COVID-19 pandemic was high. Mainly in respiratory kinesiologists and physicians.

La pandemia de COVID-19 generó globalmente una sobrecarga del sistema de salud y agotamiento mental, emocional y físico del personal. Estudios previos han reportado niveles elevados del síndrome de burnout en el personal de salud. El objetivo del estudio fue estimar la prevalencia y los factores asociados del síndrome de burnout en el personal de salud. Se realizó un estudio de corte transversal a través de la administración de una encuesta por correo electrónico durante la segunda ola de casos de COVID-19. El burnout fue evaluado mediante el cuestionario de Maslach Burnout Inventory. Se estimó la prevalencia de burnout y se analizaron los factores asociados mediantes un análisis de regresión logística multivariado. El 84% de los participantes completo la encuesta (n 133), 106 fueron médicos (80%), 11 administrativos (8%), 9 kinesiólogos respiratorios (7%) y 7 enfermeros (5%). El 62% fueron mujeres. La prevalencia de burnout fue de 38% (IC 95% 30-47%) y fue diferente según la ocupación (p < 0.001). Los médicos y los kinesiólogos respiratorios presentaron los valores más altos con una prevalencia del 40% y 89% respectivamente. En el análisis multivariado las variables que se asociaron en forma independiente al síndrome de burnout fueron: ser Médico (OR = 8.9; IC 95%: 1.1-71; p: 0.041) y ser Kinesiólogo respiratorio (OR = 137.5; IC 95%: 2-262; p 0.001). La prevalencia de síndrome de burnout en personal de salud durante la pandemia de COVID-19 fue elevada. Principalmente en los kinesiólogos respiratorios y los médicos.

Prevalencia de síndrome de burnout en personal de salud durante la pandemia de COVID-19 y factores asociados. Estudio de corte transversal / Prevalence of burnout in healthcare workers during the COVID-19 pandemic and associated factors. A cross-sectional study

Resumen La pandemia de COVID-19 generó globalmente una sobrecarga del sistema de salud y agotamiento mental, emocional y físico del personal. Estudios previos han reportado niveles elevados del síndrome de burnout en el personal de salud. El objetivo del estudio fue estimar la prevalencia y los factores asociados del síndrome de burnout en el personal de salud. Se realizó un estudio de corte transversal a través de la administración de una encuesta por correo electrónico durante la segunda ola de casos de COVID-19. El burnout fue evaluado mediante el cuestionario de Maslach Burnout Inventory. Se estimó la prevalencia de burnout y se analizaron los factores asociados mediantes un análisis de regresión logística multivariado. El 84% de los participantes completo la encuesta (n 133), 106 fueron médicos (80%), 11 administrativos (8%), 9 kinesiólogos respiratorios (7%) y 7 enfermeros (5%). El 62% fueron mujeres. La prevalencia de burnout fue de 38% (IC 95% 30-47%) y fue diferente según la ocupación (p < 0.001). Los médicos y los kinesiólogos respiratorios presenta ron los valores más altos con una prevalencia del 40% y 89% respectivamente. En el análisis multivariado las variables que se asociaron en forma independiente al síndrome de burnout fueron: ser Médico (OR = 8.9; IC 95%: 1.1-71; p: 0.041) y ser Kinesiólogo respiratorio (OR = 137.5; IC 95%: 2-262; p 0.001). La prevalencia de síndrome de burnout en personal de salud durante la pandemia de COVID-19 fue elevada. Principalmente en los kinesiólogos respiratorios y los médicos.

Abstract The COVID-19 pandemic generated an overload of the health system and mental, emotional, and physical exhaustion of workers. Previous studies have reported elevated levels of burnout syndrome in healthcare workers. The objective of the study was to estimate the prevalence and as sociated factors of burnout syndrome in healthcare workers. A cross-sectional study was conducted through the administration of an email survey during the second wave of COVID-19 cases. Burnout was evaluated using the Maslach Burnout Inventory questionnaire. The prevalence of burnout was estimated and the associated factors were analyzed using multivariate logistic regression analysis. The 84% of the participants completed the survey (N = 133), 106 were physicians (80%), 11 administrators (8%), 9 respiratory physiologists (7%), and 7 nurses (5%). 62% were women. The prevalence of burnout was 38% (95% CI 30-47%) and it was different according to the occupation (p = < 0.001). Physicians and respiratory kinesiologists presented the highest values with a prevalence of 40% and 89% respectively. In the multivariate analysis, the variables that were independently as sociated with the burnout syndrome were: being a physician (OR = 8.9; 95% CI: 1.1-71; p: 0.041) and being a respiratory kinesiologist (OR = 137.5; 95% CI: 2-262; p 0.001). The prevalence of burnout syndrome in healthcare workers during the COVID-19 pandemic was high. Mainly in respiratory kinesiologists and physicians.

Risk Factors and Rate of Recurrence after Mohs Surgery in Basal Cell and Squamous Cell Carcinomas: A Nationwide Prospective Cohort (REGESMOHS, Spanish Registry of Mohs Surgery).

Randomized studies to assess the efficacy of Mohs micrographic surgery in basal cell and squamous cell carcinomas are limited by methodological and ethical issues and a lack of long follow-up periods. This study presents the "real-life" results of a nationwide 7-years cohort on basal cell carcinoma and squamous cell carcinoma treated with Mohs micrographic surgery. A prospective cohort was conducted in 22 Spanish centres (from July 2013 to February 2020) and a multivariate analysis, including characteristics of patients, tumours, surgeries and follow-up, was performed. A total of 4,402 patients followed up for 12,111 patient-years for basal cell carcinoma, and 371 patients with 915 patient-years of follow-up for squamous cell carcinoma were recruited. Risk factors for recurrence included age, non-primary tumours and more stages or unfinished surgeries for both tumours, and immunosuppression for squamous cell carcinoma. Incidence rates of recurrence were 1.3 per 100 person-years for basal cell carcinoma (95% confidence interval 1.1-1.5) and 4.5 for squamous cell carcinoma (95% confidence interval 3.3-6.1), being constant over time (0-5 years). In conclusion, follow-up strategies should be equally intense for at least the first 5 years, with special attention paid to squamous cell carcinoma (especially in immunosuppressed patients), elderly patients, non-primary tumours, and those procedures requiring more stages, or unfinished surgeries.

Mohs micrographic surgery in dermatofibrosarcoma protuberans: Rate and risk factors for recurrence in a prospective cohort study from the Spanish Registry of Mohs Surgery (REGESMOHS) and review of the literature.

Characterization of patients, surgery procedures and the risk factors for dermatofibrosarcoma protuberans (DFSP) recurrences is poorly defined. In this study, we aimed to describe the demographics, tumor characteristics and interventions of DFSP treated with Mohs micrographic surgery (MSS) to determine the rate and risk factors for recurrence. Data were collected from REGESMOHS, a nationwide prospective cohort study of patients treated with MMS in Spain. From July 2013 to February 2020, 163 patients with DFSP who underwent MMS were included. DFSP was mostly located on trunk and extremities. Recurrent tumors had deeper tumor invasion and required higher number of MMS stages. Paraffin MMS was the most frequently used technique. Overall recurrence rate was 0.97 cases/100 person-years (95% IC = 0.36-2.57). No differences were found in epidemiological, tumor, surgery characteristics or surgical technique (frozen or paraffin MMS [p = 0.6641]) in terms of recurrence. Median follow-up time was 28.6 months with 414 patient-years of follow-up. In conclusion, we found an overall low recurrence rate of DFSP treated with MMS. None of the studied risk factors, including MMS techniques, was associated with higher risk for recurrence.

Características clínicas de la enfermedad por Coronavirus 2019 en un centro de Argentina. Cohorte retrospective / Clinical characteristics of Coronavirus Disease 2019 in a single center of Argentina. Retrospective cohort

Resumen La enfermedad por coronavirus (COVID-19) es un problema prioritario de salud. El objetivo del trabajo fue evaluar las características clínicas, evolución y gravedad de COVID-19 en un centro hospitalario de tercer nivel de la provincia de Buenos Aires, Argentina. Se realizó un estudio de cohorte retrospectiva de pacientes con COVID-19, entre el 3 de marzo y 21 de junio de 2020. Se evaluaron las características en función de la presencia o ausencia de neumonía y de la gravedad de la enfermedad. Se incluyeron 101 pacientes, la mediana de edad fue de 42 años y el 53% mujeres. Los síntomas más frecuentes fueron: fiebre 66% y tos 57%. La disnea y la fiebre se asociaron a la presencia de neumonía. Las comorbilidades más prevalentes fueron: hipertensión 22%, obesidad 18%, enfermedad cardiovascular 7% y enfermedad respiratoria crónica 7%. Los hallazgos de laboratorio más comunes fueron: linfopenia 55%, dímero-D elevado 38% y plaquetopenia 20%. El 26% presentó neumonía y el 24% fue personal de salud. En el 24% de los casos se necesitó más de una muestra de RT-PCR para el diagnóstico. Un valor moderado-alto del Índice de severidad de neumonía (PSI) fue más frecuente en la neumonía grave que en la leve (63 contra 17%, p 0.032). Se registró una mortalidad del 5%. Las características clínicas, la gravedad y evolución fueron similares a las descritas a nivel mundial. Destacamos la proporción elevada del personal de salud infectado, la tasa de falsos negativos de la RT-PCR y la utilidad del PSI para discriminar la gravedad de la neumonía.

Abstract Coronavirus disease (COVID-19) became a priority health problem. The objective was to evaluate the clinical characteristics, evolution and severity of COVID-19 in a third-level hospital, in the province of Buenos Aires, Argentina. We conducted a retrospective cohort of 101 patients with COVID-19 from March 3 to June 21, 2020. The patients were divided according to the presence or absence of pneumonia and the severity of the disease. The median age was 42 years and 53% were women. The most common symptoms were fever 66% and cough 57%. Dyspnea and fever were associated with the presence of pneumonia. The most prevalent comorbidities were: hypertension 22%, obesity 18%, cardiovascular disease 7% and chronic respiratory disease 7%. The presence of any comorbidity and hypertension were more common in severe cases. The most frequent laboratory findings were: lymphopenia 55%, elevated D-dimer 38%, and thrombocytopenia 20%. In severe diseases, the level of C-reactive protein and D-dimer were higher. Twenty six patients had pneumonia and 24% were healthcare workers. For diagnosis, more than one reverse transcriptase polymerase chain reaction (RT-PCR) sample was needed in 24% of cases. A moderate-high value of the Pneumonia Severity Index (PSI) was more prevalent in severe than mild pneumonia (63% vs. 17%, p 0.032). A mortality of 5% was registered (95% CI 1-11%). The clinical characteristics, severity and prognosis were similar to those described worldwide. We highlight a high proportion of healthcare workers were SARS-CoV-2 positive, the false negative rate of the RT-PCR and the usefulness of the PSI to discriminate the severity of pneumonia.

[Clinical characteristics of coronavirus disease 2019 in a single center of Argentina. Retrospective cohort]. / Características clínicas de la enfermedad por coronavirus 2019 en un centro de Argentina. Cohorte retrospectiva.

Coronavirus disease (COVID-19) became a priority health problem. The objective was to evaluate the clinical characteristics, evolution and severity of COVID-19 in a third-level hospital, in the province of Buenos Aires, Argentina. We conducted a retrospective cohort of 101 patients with COVID-19 from March 3 to June 21, 2020. The patients were divided according to the presence or absence of pneumonia and the severity of the disease. The median age was 42 years and 53% were women. The most common symptoms were fever 66% and cough 57%. Dyspnea and fever were associated with the presence of pneumonia. The most prevalent comorbidities were: hypertension 22%, obesity 18%, cardiovascular disease 7% and chronic respiratory disease 7%. The presence of any comorbidity and hypertension were more common in severe cases. The most frequent laboratory findings were: lymphopenia 55%, elevated D-dimer 38%, and thrombocytopenia 20%. In severe diseases, the level of C-reactive protein and D-dimer were higher. Twenty six patients had pneumonia and 24% were healthcare workers. For diagnosis, more than one reverse transcriptase polymerase chain reaction (RT-PCR) sample was needed in 24% of cases. A moderate-high value of the Pneumonia Severity Index (PSI) was more prevalent in severe than mild pneumonia (63% vs. 17%, p 0.032). A mortality of 5% was registered (95% CI 1-11%). The clinical characteristics, severity and prognosis were similar to those described worldwide. We highlight a high proportion of healthcare workers were SARS-CoV-2 positive, the false negative rate of the RT-PCR and the usefulness of the PSI to discriminate the severity of pneumonia.

La enfermedad por coronavirus (COVID-19) es un problema prioritario de salud. El objetivo del trabajo fue evaluar las características clínicas, evolución y gravedad de COVID-19 en un centro hospitalario de tercer nivel de la provincia de Buenos Aires, Argentina. Se realizó un estudio de cohorte retrospectiva de pacientes con COVID-19, entre el 3 de marzo y 21 de junio de 2020. Se evaluaron las características en función de la presencia o ausencia de neumonía y de la gravedad de la enfermedad. Se incluyeron 101 pacientes, la mediana de edad fue de 42 años y el 53% mujeres. Los síntomas más frecuentes fueron: fiebre 66% y tos 57%. La disnea y la fiebre se asociaron a la presencia de neumonía. Las comorbilidades más prevalentes fueron: hipertensión 22%, obesidad 18%, enfermedad cardiovascular 7% y enfermedad respiratoria crónica 7%. Los hallazgos de laboratorio más comunes fueron: linfopenia 55%, dímero-D elevado 38% y plaquetopenia 20%. El 26% presentó neumonía y el 24% fue personal de salud. En el 24% de los casos se necesitó más de una muestra de RT-PCR para el diagnóstico. Un valor moderado-alto del Índice de severidad de neumonía (PSI) fue más frecuente en la neumonía grave que en la leve (63 contra 17%, p 0.032). Se registró una mortalidad del 5%. Las características clínicas, la gravedad y evolución fueron similares a las descritas a nivel mundial. Destacamos la proporción elevada del personal de salud infectado, la tasa de falsos negativos de la RT-PCR y la utilidad del PSI para discriminar la gravedad de la neumonía.

State of the art of Mohs surgery for rare cutaneous tumors in the Spanish Registry of Mohs Surgery (REGESMOHS).

BACKGROUND: The use of Mohs micrographic surgery (MMS) for rare cutaneous tumors is poorly defined. We aim to describe the demographics, tumor presentation and topography, surgery characteristics and complications of MMS for rare cutaneous tumors in a national registry. METHODS: Prospective cohort study of patients treated with MMS in Spain between July 2013 and June 2018. The inclusion criteria were patients with cutaneous tumors with final diagnosis different from basal cell carcinoma, squamous cell carcinoma, dermatofibrosarcoma protuberans, or any kind of melanoma. RESULTS: Five thousand and ninety patients were recorded in the registry, from which only 73 tumors (1.4%) fulfilled the inclusion criteria: atypical fibroxanthoma (18), microcystic adnexal carcinoma (10), extramammary Paget's disease (7), Merkel cell carcinoma (5), dermatofibroma (4), trichilemmal carcinoma (4), desmoplastic trichoepithelioma (4), sebaceous carcinoma (3), leiomyosarcoma (2), porocarcinoma (2), angiosarcoma (2), trichoblastoma (1), superficial acral fibromyxoma (1), and others (10). No intra-surgery morbidity was registered. Postsurgery complications appeared in six patients (9%) and were considered mild. Median follow-up time was 0.9 years during which three Merkel cell carcinomas, one angiosarcoma, one microcystic adnexal carcinoma, and four others recurred (12.3%). CONCLUSION: This national registry shows that rare cutaneous tumors represent a negligible part of the total MMS performed in our country with a low complication rate.

Atypical Presentation of Primary Cutaneous CD8 Positive Aggressive Epidermotropic Cytotoxic T-Cell Lymphoma.

Primary cutaneous CD8 positive aggressive epidermotropic cytotoxic T-cell lymphoma (PCAT) is a rare and heterogeneous entity with less than 100 published cases to date. A 68-year-old man was following up for an inflammatory lichen-lupus overlap dermatosis of 3 years duration. Treatment with methotrexate was started, observing a dramatic change in the skin lesions that became infiltrated plaques and generalized ulcerated tumours distributed over trunk and extremities. Histological study showed marked epidermotropism of CD8 positive cells and monoclonality was demonstrated by the polymerase chain reaction. Diagnosis of PCAT was concluded. Treatment with polychemotherapy was indicated. The PCAT is characterized by a rapid clinical history of generalized papules, plaques, nodules and tumours with frequent ulceration and necrosis. Although it has no pathognomonic clinical features, there are clinical, histological and prognostic data that define them as a group and differentiate them from other lymphomas. Exceptionally, there are cases reported which have been triggered following treatment with immunosuppressive drugs. In our patient we think that PCAT was triggered by the transformation of a pre-existing dermatosis, which had never showed a lymphoproliferative profile in biopsies before. A possible pathogenic mechanism is that in some inflammatory dermatoses, chronic antigenic stimulation in a situation of iatrogenic immunosuppression may favour the development of a malignant clonal T cell.

Differences of Mohs micrographic surgery in basal cell carcinoma versus squamous cell carcinoma.

BACKGROUND: The two main tumors treated with Mohs micrographic surgery (MMS) are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). There are no studies analyzing whether MMS is different when treating these two types of tumors. OBJECTIVE: We aim to compare the characteristics of the patients, the tumors, and MMS, and first-year follow-up of MMS in BCC and SCC. METHODS: REGESMOHS is a prospective cohort study of patients treated with MMS. The participating centers are 19 Spanish hospitals where at least one MMS is performed per week. Data on characteristics of the patients, tumors, and surgery were recorded. The follow-up was done with two visits: the first visit within 1 month after surgery and the second one within the first year. RESULTS: From July 2013 to April 2017, a total of 2,669 patients who underwent MMS were included in the registry. Of them, 2,448 (93%) were diagnosed with BCC, and 181 (7%) were diagnosed with SCC. Patients with SCC were older than those with BCC (median age 73 years vs. 68 years) and presented immunosuppression more frequently. The tumor size was significantly larger in the SCC group. Regarding surgery, deeper invasion was more frequent in SCC, resulting in larger defects. Despite this, SCC did not require more stages to get clear margins or more time in the operating room. Incomplete Mohs was more frequent in the SCC group (6%) than in the BCC group (2%). The incidence of perioperative complications was higher when treating SCC. There were more relapses in the first-year follow-up in the SCC group. CONCLUSION: There are significant differences when comparing MMS in BCC and SCC. Knowledge of these differences can help to prepare the patient and plan the surgery, optimizing results.