In vitro analysis of interactions between Pseudomonas aeruginosa and Candida albicans treated with silver sulfadiazine in wound infections.

Background: Microorganisms tend to rely on close relationships with other species to survive. Consequently, biofilms formed by interactions of different species have been shown to delay the wound healing process. Studies suggest these mixed-population infections contribute to the development of drug resistance and inhibition of host immune response. Silver sulfadiazine (SSD) has been shown to effectively decrease the risk of infection in an open wound. Typically, these are bacterial wound infections; however, the role of fungal species needs further attention. Objectives: The purpose of this in vitro study was to determine the effect of SSD on interactions between Pseudomonas aeruginosa 09-009 (PA1) or P. aeruginosa 09-010 (PA2) and Candida albicans ATTC 64550 (CA). Methods: A mixture of 4 mL of tryptic soy broth (TSB) and 100 µL of CA and/or PA1 or PA2 (∼106 log cfu/mL) inoculums were deposited into either wells or vials. The wells or vials were then sonicated (50 W for 10 s) to separate microorganisms attached to the walls. After incubation, cell counts were performed at 24 and 48 h for each microorganism using specific media. Results: Our results show that without SSD treatment, P. aeruginosa exhibits an inhibitory effect on C. albicans. Treatment with SSD demonstrated significant reduction of P. aeruginosa; however, C. albicans persisted. This experiment demonstrates that SSD was effective in reducing the bioburden of both P. aeruginosa strains after 24 and 48 h; however, it was not as effective in reducing C. albicans. Conclusions: The data suggest that for polymicrobial mixed infections containing Pseudomonas spp. and C. albicans, treatment with SSD may be beneficial but does not provide adequate microorganism eradication. As such, added treatments that provide coverage for Candida infection are necessary. Additional in vivo studies are needed to obtain a better understanding of the complex interactions between these organisms.

Systematic review of the utilization of botulinum toxin in Mohs micrographic surgery.

The use of botulinum toxin for off-label indications has become more prevalent, but the specific benefits in Mohs micrographic surgery (MMS) have not yet been fully elucidated. A systematic review was performed of PubMed, Cochrane, EMBASE, and Scopus databases to identify all articles describing the use of botulinum toxin in MMS. Analysis was subdivided into scar minimization, parotid injury, and pain management. A total of nine articles were included. Scar minimization and treatment of parotid injury were the most reported uses. One case reported the use of botulinum toxin for pain management. Off label uses of botulinum toxin are being explored. Additional research is warranted to determine the efficacy and utility of botulinum toxin in MMS.

Squamous cell carcinoma: 2021 updated review of treatment.

Squamous cell carcinoma is the second most common cutaneous malignancy, requiring early diagnosis to prevent metastasis. Updated guidelines in the definition of clinical features, diagnostic modalities, grading, staging, surgical, and nonsurgical treatment methods are necessary. Diagnostic methods from biopsy, dermoscopy, and reflectance confocal microscopy have improved to include high-frequency ultrasonography, optical coherence tomography, and computed tomography. Non-surgical treatment methods include topical therapy, cryosurgery, photodynamic therapy, and radiation. Surgical treatment methods include surgical excision with margins and Mohs surgery. Clinical trials encourage further research to address the knowledge base of genetic variations and lymph node metastasis.

The 100 most influential skin cancer publications: a citation analysis.

BACKGROUND: As skin cancer is the most common cancer in the U.S., many publications focus on cutaneous malignancies. The objective was to identify and analyze the 100 most-cited articles pertaining to skin cancers to provide clarity on past, and insight for future research. METHODS: Using a two-stage search of Thomson Reuters Web of Science database, the 100 most-cited skin cancer articles between 1945 and 2018 were identified and analyzed. RESULTS: The articles were cited an average total of 558.49 times (range: 259 to 3429). There were relatively few significant publications until 1988. Linear correlation revealed that journal impact factor was not correlated with average number of citations per year per article (R2=0.06). Molecular pathogenesis and UV exposure were the most common topics. The topics that received the highest average citations per year per article were prevention (50.44 citations per year), diagnosis (47.32 citations per year), and management (41.37 citations per year). Basic science articles accounted for the most publications, followed by narrative literature reviews. CONCLUSIONS: These results may indicate that future publications with similar characteristics are more likely to be cited and thus, more influential.

Readability of Online Patient Education Materials for Interventional Pain Procedures.

Background The internet has had an enormous influence on the field of medicine. In this regard, Statista, a market and consumer data company, estimated in 2019 that more than half the world's population (>four billion people) were active internet users. Accessing the World Wide Web has become the second nature for most. In the medical field, many patients look to the internet for information regarding certain procedures. The purpose of this study, therefore, was to assess the readability level of more than 492 online sources with information on a wide array of interventional pain procedures. Objective The aim is to determine the readability of online patient educational materials for interventional pain procedures. Study design This is a retrospective review. Methods We downloaded and reformatted to plain text 492 internet-based patient educational materials for 17 different interventional pain procedures. Plain text was processed using Readability Studio (Oleander Software Ltd., Vandalia, Ohio, USA), which employs 10 quantitative readability scales that are widely used and accepted in the medical literature. Results The software determined the average reading level (or grade level) of the 492 online sources we examined to be 12.1, with a range of 10.9 to 13. Limitations Google is not the only online search engine patients utilize for information, and the top links for each search could change over time. Also, some patients prefer videos rather than text to learn about their disease and treatment options. Finally, depending on their provider, the links that patients are directed to may be significantly more or less readable. Conclusions The average American adult reads at the eighth grade level. The National Institutes of Health and the American Medical Association have recommended education materials be made available at the third to seventh grade level. Our analysis shows patient educational materials found online for interventional pain procedures to be overly technical, with an average reading level (or grade level) of 12.1.

Descriptive Analysis of Federal and State Interventional Pain Malpractice Litigation in the United States: A Pilot Investigation.

BACKGROUND: The aim of this study was to examine and appreciate characteristics of malpractice lawsuits brought against interventional pain specialists. OBJECTIVES: To examine and appreciate characteristics of malpractice lawsuits brought against interventional pain specialists. STUDY DESIGN: Retrospective review. SETTING: Jury verdicts and settlement reports of state and federal malpractice cases involving interventional pain practitioners from January 1, 1988, to January 1, 2018 were gathered from the Westlaw online legal database. METHODS: Jury verdicts and settlement reports of state and federal malpractice cases involving interventional pain practitioners from January 1, 1988, to January 1, 2018 were gathered from the Westlaw online legal database. Data collected for each case included year, state, patient age, patient gender, defendant specialty, legal outcome, award amount, alleged cause of malpractice, and factors in plaintiff's decision to file. After elimination of duplicates and applying inclusion/exclusion criteria to our initial search yielding over 1,500 cases, a total of 82 cases were included in this study. RESULTS: A total of 57.3% of cases resulted in a jury verdict in favor of the defendant, whereas 41.5% favored the plaintiff. When comparing cases that were performed in the operating room to cases performed outside the operating room, we found the jury verdicts to favor the plaintiff 83.3% of the time for operating room procedures (P = 0.003). In other words, interventional pain practitioners were more likely to be found at fault for complications from procedures performed in the operating room. To eliminate confounders, a logistical regression was performed and confirmed operating room procedures were an independent predictor of a verdict awarded to the plaintiff (P = 0.008). The median amount awarded to the plaintiff for all cases was $333,000, and the single highest award amount was $36,636,288. The median payout for operating room procedures was $450,000 (P = 0.010), which was significantly different from the median payout for nonoperating room procedures. Procedure categorization demonstrated a statistically significant difference in jury verdicts (P = 0.01411) and procedural error was the leading reason for pursuing litigation, followed by lack of informed consent and unnecessary procedure performed. LIMITATIONS: There is more than one database that captures medicolegal claims brought against practitioners. Westlaw, which has been previously utilized by other studies, is only one of them and the extent to which overlap exists in unclear. For each, data input are not necessarily consistent and data capture are not complete. As a result, there could exist a skew toward more severe complications and the details of individual cases likely vary. During data extraction, we found that all details of the procedure were not always included. For example, not all cases specified the type of injectate utilized for epidural injection (i.e., local anesthetic, steroid, mixture, and others) or route of injection (i.e., transforaminal vs. interlaminar). Moreover, as previously mentioned, cases that are settled out of court or finalized prior to trial are not necessarily reported by the Westlaw database, and therefore were not always included in our data search. CONCLUSIONS: Overall, interventional pain medicine physicians were favored by jury verdicts for malpractice claims. However, when filtering by procedure or setting, jury verdicts favored the plaintiff in some cases. KEY WORDS: Interventional pain, medical, malpractice, anesthesiology.

Epicardial Fat: A New Therapeutic Target in Psoriasis.

Psoriasis is a chronic inflammatory disease affecting over 8 million Americans. Importantly, patients with psoriasis are at an increased risk of developing atherosclerosis, coronary artery disease, and myocardial infarctions. Several studies have suggested that psoriasis may be an independent risk factor for cardiovascular disease given their shared inflammatory properties and pathogenic similarities. Epicardial fat is also linked to cardiovascular disease and may be an independent risk factor for atherosclerosis. It has been proposed that measuring epicardial fat tissue may serve as a useful subclinical measure of cardiovascular disease in psoriasis patients. Echocardiography has been increasingly adopted as an accurate, minimally invasive, and cost-effective measure of determining the volume and thickness of epicardial fat. Using echocardiographic measures of epicardial fat thickness as a marker of cardiovascular disease and therapeutic target in psoriasis patients may provide clinicians with a means to better manage and hopefully prevent deleterious downstream effects.

What patients see online: assessing the online identities of Pennsylvania dermatologists.

INTRODUCTION: Patients use the internet to search for health-related information. We sought to characterize the information that patients find when searching for dermatologists on Google. METHODS: The Centers for Medicare and Medicaid Services (CMS) Physician Comparable Downloadable File was utilized to identify all Medicare-participating dermatologists practicing in Pennsylvania (PA). A custom Google-based search engine was used to search each dermatologist. Up to the top 10 results for each physician were then sorted into: (1) physician, hospital, or healthcare system, (2) third-party, (3) social media, (4) academic journal articles, or (5) other. RESULTS: Within the CMS, 519 health care providers (53.9% male, 46.1% female) self-identified as dermatologists practicing in PA. At least one search result was obtained for each physician (4,963 total search results). About 30.6% (1,519) search results were hospital, health system, or physician-controlled websites, and 26.6% (1,318) were third-party websites (1,318; 26.6%). Social media websites accounted for 601 (12.1%) hits whereas peer-reviewed academic journal websites generated 135 (2.7%) results. One-way chi-square analysis showed domains were not randomly distributed across the five categories (P<0.0001). CONCLUSION: Dermatologists should be better aware of their digital presence and the strategies to better control their online identity.

Analysis of patient perceptions of Mohs surgery on social media platforms.

This study assessed social media content to improve understanding of patient experiences with Mohs surgery. An initial search of public Instagram posts and tweets tagged with "#mohssurgery" or "@mohssurgery" identified 1692 Instagram posts and 115 tweets, of which 1390 and 94 were eliminated, respectively, given that they did not directly include a patient's own experience. The team analyzed the posts/tweets for patient gender, timing of post prior to or after their procedure, and classified themes related to patients' experience with Mohs. Analysis showed that 91.4% of Instagram posts and 75.0% of tweets were published post-Mohs surgery, with the majority made by women. The most common theme on Twitter was updating followers on treatment progress (30.0%) and on Instagram, the most common theme was spreading awareness of skin cancer/encouraging others to protect their skin (18.9%). Other common themes included concern of appearance during recovery process, scars after treatment, and healing progress. Social media has the ability to provide a platform for patients to impart their personal experiences with Mohs surgery performed on skin cancer lesions.

Wound healing elective: an opportunity to improve medical education curriculum to better manage the increasing burden of chronic wounds.

Chronic wounds are highly prevalent and have become a public health crisis. Successful treatment of chronic wounds requires that healthcare providers study both the pathophysiology of wound healing and maintain knowledge of the most current wound care guidelines set forth by the Agency for Healthcare Research and Quality. Unfortunately, medical students currently receive limited wound care training. A focused and well-organized course integrating a diverse group of medical and surgical faculty, residents, and medical students in the clinical years has been created to address this growing medical issue. The goal of such curricular innovations is to help future physicians gain exposure to chronic wounds and develop crucial clinical skills so they enter residency prepared to offer basic treatments and prevent rapid deterioration of the many wounds they will encounter.

Implementation of a Competency-based Pressure Ulcer Curriculum for Medical Students: Outcomes from an Educational Intervention Study.

A paucity of research exists on medical student pressure ulcer education. PURPOSE: This study examines medical student competency outcomes following implementation of a competency-based curriculum that included a pressure ulcer component in its educational intervention. METHODS: Over a 5-year period, 645 medical students completed the curriculum, which included a preceptor-led didactic session, online study resources, clinical experiences, and a brief online competency assessment. The assessment involved knowledge of risk factors, wound staging/classification, and prevention and management strategies and included short answer and extended matching questions. A performance standard was set; students not achieving this standard underwent remediation and reassessment. The curriculum was implemented in 3 phases with quality improvement (QI) between each phase. The average competency assessment score and passing rates were determined for each phase. Mean scores for each phase were compared using an analysis of variance test. RESULTS: Mean competency assessment scores increased significantly after each QI from 17.5 (range 11-23) to 18.3 (range 12-24) to 19.8 (range 12-25) in phases 1, 2 and 3, respectively [F(2,642) = 59.502, P <.001]; the performance standard was raised after both QI points. Overall, 8.7% of students underwent remediation and reassessment, but all achieved the performance standard on their second attempt. CONCLUSION: Through a thoughtful QI process that involved carefully aligning all curricular elements (the instructional activities and the assessment), a focused and accountable curriculum was developed that ensured all medical students in the program would achieve a basic level of competency. Increasingly, accreditation agencies are asking medical schools to move toward competency-based curricula. This curriculum represents an important step in this direction.