Bilateral Forehead Rotation Flap with Skin Substitute Application for Convexity Replacement.

Large forehead defects pose reconstructive challenges, considering the tissue inelasticity and the need to preserve symmetry of the eyebrow and hairline. Local skin flaps and primary closures are mainstays of forehead reconstruction with many techniques reported, but they may not cover the entire defect. Further closure options with acceptable cosmesis are limited. While providing a functional alternative, skin grafting may take on an atrophic concavity and shiny texture. Free flaps similarly may not accurately replicate the contour of the forehead and may be discordant with the texture of adjacent skin. We describe a reproducible technique for closing a large central forehead defect in a single-stage local flap while retaining symmetry of eyebrows and neurovascular integrity. We also propose serially applying a skin substitute to the remaining portion of the defect to recreate forehead convexity and potentially expedite healing. This technique may represent a viable and reproducible method for recreating the natural contour of the forehead when complete closure may not be an option.

Educational Interventions to Support Primary Care Provider Performance of Diagnostic Skin Cancer Examinations: A Systematic Literature Review.

To our knowledge, there is no available standardized educational curriculum designed to promote the incorporation of skin cancer examinations and procedures into general practice. To explore the contemporary training landscape, we conducted a systematic review of educational interventions designed to support skin cancer diagnostic examinations by primary care providers (PCPs). Our review uniquely encompasses all PCPs, including practicing physicians, residents, and advanced practice practitioners (APPs). The objective of this study is to review and synthesize worldwide data on educational interventions addressing PCP performance of skin cancer diagnostic examinations. A systematic review was performed in MEDLINE, Cochrane, EMBASE, and Scopus for English language articles worldwide published from 2000 onwards. Articles were screened for eligibility, and possibly overlapping datasets were resolved. Data extracted included curriculum content, delivery format, and educational outcomes. This review followed the PRISMA guidelines. A total of 63 studies were selected for data inclusion with one addressing training for resident physicians, 4 for APPs, and the remainder for practicing physicians. Educational interventions included in this review reflect the pre-SARS-CoV-2 pandemic educational environment: half provided live/synchronous instruction of about 5-h duration on average, and a quarter featured interactive components. Less than a quarter of interventions included practice change as a specific reported outcome. Without sustainable practice change, the anticipated long-term benefits of early cancer detection in patients remain limited. Previous and existing educational interventions designed to support skin cancer detection by PCPs demonstrate heterogeneous curriculum content, delivery methods, and educational outcomes. An ideal intervention would teach consensus-derived clinical competencies, provide meaningful learner feedback, and measure outcomes, such as knowledge/competency, confidence/attitudes, and practice change, using validated instruments.

Therapeutic challenges in managing pediatric psoriasis.

BACKGROUND: Each year, 20,000 patients aged <10 years are diagnosed with psoriasis. Pediatric-onset psoriasis has many similarities to adult-onset disease, and previous studies suggest that the incidence might be increasing in both populations. OBJECTIVE: The challenges that arise when treating patients with psoriasis, especially those age <12 years, are summarized, as well as the limited available treatment options for treating pediatric patients with psoriasis and the evidence supporting each of them. METHODS: Recently published guidelines by the American Academy of Dermatology and the National Psoriasis Foundations, as well as guidelines published by the German Society of Dermatology, provide considerable insight in managing patients who have this condition. The latest studies on pediatric psoriasis treatment were reviewed, including recent and current clinical trials with U.S. Food and Drug Administration approved and nonapproved medications, case reports, case series, and reviews. The authors also reviewed American and European guidelines, as well as recommendations from expert panels. RESULTS: Currently, only six medications are approved by the U.S. Food and Drug Administration for the treatment of pediatric psoriasis: three biologics and three topical. Many off-label topical treatments have been used in pediatric psoriasis, with variable effectiveness and safety profiles. Data from adult clinical trials, as well as case reports and series from pediatric patients, suggest that other biologic medications are effective for pediatric psoriasis. CONCLUSION: Many questions remain unanswered, leaving clinicians facing multiple challenges when encountering pediatric patients with psoriasis. This summation will help provide an overview of current on- and off-label medications for pediatric psoriasis. Pediatric clinical trials should be implemented to obtain data that can result in expanding the therapeutic spectrum for this population, parallel to their adult counterparts.

Relationship Between Methylmercury Contamination and Proportion of Aquatic and Terrestrial Prey in Diets of Shoreline Spiders.

Terrestrial organisms such as shoreline spiders that consume prey from aquatic food webs can be contaminated with methylmercury (MeHg). However, no studies have examined the relationship between MeHg contamination of shoreline spider taxa and the proportion of aquatic and terrestrial prey in their diets. The present study had 2 objectives: 1) determine concentrations of MeHg in 7 taxa of shoreline spiders, and 2) assess the relationship between concentrations of MeHg in spiders and the proportion of aquatic and terrestrial prey in spider diets. We collected shoreline spiders, emergent aquatic insects, and terrestrial insects from in and around 10 experimental ponds. Methylmercury concentrations were greatest in spiders, intermediate in aquatic insects, and lowest in terrestrial insects. The elevated MeHg concentrations in spiders indicate that they were feeding, at least in part, on emergent aquatic insects. However, variability in MeHg concentration observed among spider taxa suggested that the proportion of aquatic and terrestrial prey in spider diets likely varied among taxa. We estimated the proportion of aquatic and terrestrial prey in the diet of each spider taxon from the nitrogen (δ15 N) and carbon (δ13 C) isotope values of spiders and their potential aquatic and terrestrial prey items. The median proportion of aquatic prey in spider diets varied by almost 2-fold, and MeHg concentrations in shoreline spiders were strongly correlated with the proportion of aquatic prey in their diet. In the present study, we demonstrate for the first time that the degree of connectivity to aquatic food webs determines MeHg contamination of shoreline spiders. Environ Toxicol Chem 2019;38:2503-2508. © 2019 SETAC.