Lower Extremity Salvage in the Setting of Bullous Pemphigoid Exacerbation: A Case Report.

Bullous pemphigoid is an autoimmune blistering disease where patients suffer from painful bullae, often covering large portions of the skin and requiring management with immune-suppression. Our case report of recurring bullous pemphigoid illustrates the importance of considering immunosuppressive perioperative management in patients with a history of autoimmune blistering even when the disease has been quiescent for some time. With multidisciplinary care and immune suppressive therapies in the perioperative period, a free flap complicated by recurrent bullous pemphigoid can be salvaged.

The show must go on: Dermatologic procedural education in the era of COVID-19.

COVID-19 procedural restrictions and concerns from both practitioners and patients have led to a decrease in cosmetic procedures performed. Reduced clinic space, the necessity of distancing between people, and patient preference for a smaller care team may restrict trainees from observing, assisting with, or performing procedures. Thus, trainees may be limited in their ability to learn, practice, and meet the required number of cases to achieve competence, subsequently necessitating a sustained demand for alternative methods of learning. In this review, we examine the efforts made thus far by both dermatologists and dermatology organizations to meet the educational procedural needs of trainees and compensate for limitations during the pandemic and highlight areas in which innovation may still be needed.

Cutaneous basal cell carcinoma mimicking small cell carcinoma.

Neuroendocrine differentiation seen in basal cell carcinomas (BCC) is not generally appreciated by oncologists and can introduce a component of confusion when diagnosing a tumor and developing a management plan. Understanding that BCC commonly have this feature can assist the treating oncologist.

Sentinel node mapping and ductal carcinoma in situ.

BACKGROUND: Pure ductal carcinoma in situ (DCIS) is typically unassociated with a risk of regional lymph node involvement. Retrospective series maintain that larger tumors or high-grade histopathology may harbor a risk of lymph node involvement. PURPOSE: Our community hospital retrospectively reviewed a series wherein women with DCIS were subjected to sentinel lymph node biopsy based on large tumor size and/or high-grade histopathology. MATERIALS AND METHODS: 232 consecutive women with a diagnosis of pure DCIS were evaluated independently by two breast surgeons, one who typically offers sentinel node mapping to patients with tumors larger than 10 mm and the other who offers sentinel node mapping to women with grade 3 tumors. 60 women (26%) underwent sentinel node mapping along with appropriate surgery directed to the breast. Women were offered risk-adjusted adjuvant radiotherapy and anti-endocrine therapy. RESULTS: At a median follow-up of 18 months (range 6-132 months), 9 women (15%) were identified with regional axillary nodal disease. A statistical analysis was conducted between women who did or did not undergo sentinel node mapping because there was overlap in large tumor size and high grade between the two groups. A univariate logistic regression statistic showed a trend toward a significant relationship between grade 3 tumors and a risk of occult nodal involvement. This was not confirmed by multivariate analysis. CONCLUSIONS: In our moderate-sized surgical experience evaluating women with pure DCIS who underwent a sentinel node mapping due to large tumor size or high grade histology, we were unable to confirm that either is predictive of occult node involvement.

Central venous catheter placement after ultrasound guided peripheral IV placement for difficult vascular access patients.

OBJECTIVES: Ultrasound guided peripheral intravenous catheters (USPIV) are frequently utilized in the Emergency Department (ED) and lead to reduced central venous catheter (CVC) placements. USPIVs, however, are reported to have high failure rates. Our primary objective was to determine the proportion of patients that required CVC after USPIV. Our secondary objective was to determine if classic risk factors for difficult vascular access were predictive of future CVC placement. METHODS: We performed a retrospective review for patients treated at a large academic hospital. Patients were identified by electronic health record and were restricted to age older than 21 years, had received USPIV, and admittance. Exclusion criteria included an existing CVC. Descriptive statistics, t-tests, chi-square proportions, and logistic regression were performed to test associations. RESULTS: Of 363 eligible patients, 20 were excluded allowing for 343 for analysis. Of 343, 45 (13.1% 95% CI 9.9-17.1%) required CVC after USPIV. For secondary outcomes, no expected characteristics (diabetes, end-stage renal disease, IV drug abuse, peripheral vascular disease, or sickle cell disease) were predictive of CVC placement. The only predictive variables were admission to ICU/stepdown and length of stay. Each additional day of hospitalization had an OR 1.11 (95% CI 1.06-1.16%) of having a CVC placed. CONCLUSION: Of those admitted after USPIV placement, approximately 7 out of every 8 patients did not require a subsequent CVC. Of the nearly 1 in 8 patients that required a CVC, factors associated with CVC placement were admission to a higher level of care and length of stay.