Randomized Controlled Trial of Preoperative Topical Decolonization to Reduce Surgical Site Infection for Staphylococcus aureus Nasal Swab-Negative Mohs Micrographic Surgery Patients.

BACKGROUND: Surgical site infection (SSI) is mainly due to endogenous bacteria. Topical decolonization is a preoperative intervention currently advised for proven nasal carriers of Staphylococcus aureus (S. aureus). OBJECTIVE: The authors assessed whether topical decolonization could be of benefit for patients who are not nasal carriers of S. aureus. METHODS AND MATERIALS: The authors performed a randomized controlled trial of S. aureus nasal swab-negative patients. Five days before Mohs surgery topical decolonization with nasal mupirocin and chlorhexidine, body wash was started. The control group had no intervention. RESULTS: In the week after Mohs surgery, the infection rate in the intervention group was 2% (n = 661, 14) and that of the control group was 4% (n = 689, 29). CONCLUSION: Topical decolonization reduces SSI in nasal swab-negative Mohs surgery patients.

Oral antibiotics versus topical decolonization to prevent surgical site infection after Mohs micrographic surgery--a randomized, controlled trial.

BACKGROUND: The optimal method of reducing the risk of surgical site infection (SSI) after dermatologic surgery is unclear. Empiric, preoperative antibiotic use is common practice but lacks supporting evidence for its efficacy in preventing SSI. Risk stratification for patients at high risk of postoperative SSI based on a nasal swab is a viable strategy when coupled with topical decolonization for positive carriers. We compared the rates of infection in patients undergoing Mohs micrographic surgery (MMS) with nasal carriage of Staphylococcus aureus who received oral antibiotics or topical decolonization. METHODS: A randomized, controlled trial with 693 patients was conducted over a 30-week period at a single surgical practice. Patients were stratified into nasal carriers or noncarriers of S. aureus based on a preoperative nasal swab. Nasal carriers of S. aureus were randomized to receive topical decolonization with intranasal mupirocin twice daily plus 4% chlorhexidine gluconate body wash daily for 5 consecutive days before surgery or statim pre- and postoperative doses of oral cephalexin. RESULTS: One hundred seventy-nine patients (25.8%) were identified as carriers of S. aureus. Ninety received topical decolonization, and 89 received oral antibiotics. These groups were compared with a swab-negative Mohs surgical cohort over the same time period. There were no significant differences between the groups in terms of demographic characteristics or comorbidities. Nine percent of patients receiving oral antibiotic prophylaxis and 0% receiving topical decolonization developed early SSI (p = .003). CONCLUSION: In patients with demonstrable carriage of S. aureus, topical decolonization resulted in fewer SSI than in patients receiving perioperative oral antibiotics. Antibiotics should be reserved for clinically suspected and swab-proven infections rather than being prescribed empirically. Further efforts should be directed toward optimizing endogenous risk factor control for all patients presenting for MMS.

Late-stage human African trypanosomiasis in a Sudanese refugee.

A 19-year-old Sudanese woman, who had lived for about a decade in Ugandan refugee camps, was referred for investigation of a 12-month history of a generalised rash. Two months later, her condition had deteriorated to include cachexia and drowsiness. Despite initial negative findings on investigation, human African trypanosomiasis (HAT) was suspected, and parasites were found in a double-centrifuged sample of cerebrospinal fluid. Eflornithine, the appropriate drug for treatment of late-stage disease, was obtained through the World Health Organization. This case highlights the diagnostic and therapeutic difficulties in managing late-stage HAT in a non-endemic country.

Clear cell change in eccrine glands is not associated with diabetes.

The significance of clear cell change (clear reticulated cytoplasmic change) in the secretory portion of eccrine glands remains an enigma. It has been postulated to be a product of defective cellular glucose metabolism and potentially a predictor of diabetes. A series of 61 specimens from 38 patients were assessed to establish any demographic, seasonal, or metabolic associations. Sixty-one specimens from 38 patients with eccrine clear cell changes were identified prospectively by one of the authors (T.W.B.). Each specimen was stratified by site, age, sex, and season. For each patient, the general practitioner was contacted and diabetes status was ascertained. This was possible in 34 of 38 patients. Fifty routine consecutive cases from the archive in both summer and winter were studied for possible clear cell changes, looking for any seasonal variance. No clear association between the presence of eccrine clear cell change and any demographic or seasonal pattern was found. Specifically, there did not seem to be any significant association between diabetes and this histological finding. The prevalence of diabetes in cases with eccrine clear cell change was similar to the background population prevalence of diabetes in Australia (7.9% vs. 7.4%). The incidence of this finding is approximately 1 case in 189 specimens (0.5%) examined in this practice. Clear cell change within the secretory portion of eccrine glands seems to be an incidental finding, with no clear clinicopathological implication. In particular, there does not seem to be any association with diabetes.

Melanoma in private practice: do dermatologists make a difference?

Malignant melanoma is a major contributor to Australian morbidity and mortality. In this era of resource rationalisation, we seek to address the issue of whether routine full-skin examination by a dermatologist, rather than focussed examination of flagged lesions, will increase melanoma diagnosis. A retrospective chart review was undertaken between 1 July 2007 and 30 June 2008 in a private dermatology group practice in order to ascertain the number and characteristics of incidentally detected melanomas on routine skin examination. A total of 94 melanomas were detected during this 12-month period. Of these, 57 (60.6%) were incidentally detected by the dermatologist, 41 (71.9%) were in situ melanomas and 16 (28.1%) were invasive melanoma. Of the invasive lesions, 15 (94%) were 'thin' (less than 1.0 mm Breslow thickness). The majority of melanomas were found in men, and were distributed in areas of high cumulative sun exposure. Nine (9.6%) lesions were clinically misdiagnosed by the dermatologists and picked up on histopathology. This audit reaffirms the usefulness of routine full-skin examination by dermatologists in detecting de novo melanoma as part of the global strategy in reducing the burden of melanoma in Australia.

Giant basal cell carcinoma masquerading as an osteogenic sarcoma.

An 88-year-old man presented to the dermatology outpatient clinic with an 11-month history of a rapidly growing mass overlying a clavicular fracture site. The lesion was 8 x 6 cm, painful, fixed to deeper structures and ulcerated. Superficial and deep biopsies yielded invasive basal cell carcinoma. Imaging demonstrated extensive soft tissue invasion into muscle, bone and potentially into the lung parenchyma. Due to complications arising from subsequent diagnostic procedures, the patient declined further invasive tests. The cutaneous lesion was treated with palliative radiotherapy. We explore the literature regarding the tumorigenic effects of peri-fracture cytokines on the biological behaviour of basal cell neoplasms.

Endothelial and platelet activation in acute ischemic stroke and its etiological subtypes.

BACKGROUND AND PURPOSE: Activation of endothelial cells and platelets is an important mediator of atherothrombosis. Markers of endothelial cell and platelet activation such as soluble adhesion molecules can be measured in plasma. We hypothesized that patients with acute ischemic stroke would have increased blood concentrations of soluble E-selectin and von Willebrand factor (vWF), primarily reflecting activation of endothelial cells, and increased concentrations of soluble P-selectin and platelet-derived microvesicles (PDM), primarily reflecting activation of platelets, compared with healthy controls. We also hypothesized that these markers would be differentially elevated in ischemic stroke caused by large- and small-artery atherothrombosis compared with cardiogenic embolism. METHODS: We conducted a case-control study of 200 hospital-referred cases of first-ever ischemic stroke and 205 randomly selected community controls stratified by age, sex, and postal code. Using established criteria, we classified cases of stroke by etiological subtype in a blinded fashion. The prevalence of vascular risk factors and blood concentrations of E-selectin, P-selectin, vWF antigen, and PDM were determined in stroke cases within 7 days and at 3 to 6 months after stroke and in controls. RESULTS: Mean blood concentrations of soluble E-selectin, P-selectin, and PDM within 7 days of stroke onset were all significantly higher in cases compared with controls. At 3 to 6 months after stroke, the mean blood concentrations of E-selectin and P-selectin fell significantly below that of controls, and PDM concentrations remained elevated. There was a strong, graded, and independent (of age, sex, and vascular risk factors) association between increasing blood concentrations of E-selectin during the acute phase and all etiological subtypes of ischemic stroke, particularly ischemic stroke caused by large-artery atherothrombosis. There was also a significant, graded, and independent association between increasing blood concentrations of vWF during the acute phase and ischemic stroke caused by large-artery atherothrombosis. CONCLUSIONS: We have demonstrated significant associations between acute elevation of blood markers of endothelial cell and platelet activation and ischemic stroke and between acute elevation of blood markers of endothelial cell activation and ischemic stroke caused by large-artery atherothrombosis. Persistent elevated blood concentrations of PDM may be a marker of increased risk of ischemic stroke.