Red man syndrome caused by vancomycin powder.

Red man syndrome (RMS) is a well-known hypersensitivity reaction caused by intravenous administration of vancomycin, with symptoms ranging from flushing, erythematous rash, pruritus, mild to profound hypotension, and even cardiac arrest. RMS has not previously been described from local application of vancomycin powder in a surgical wound, a technique increasingly utilized for infection prophylaxis in many surgical disciplines including neurosurgery. We describe the first reported case of RMS as a result of local intra-wound application of vancomycin powder for infection prophylaxis. A 73-year-old male with a history of Parkinson's disease underwent 2-stage deep brain stimulation implantation surgeries. Vancomycin powder was applied locally in the surgical wounds for infection prophylaxis during both of the surgeries. The patient developed a well-demarcated, geometric erythematous pruritic rash following the second surgery that was clinically diagnosed as RMS and resolved without sequelae.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System.

As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and Alternative Payment Models in dermatology.

With the introduction of the Medicare Access and Children's Health Insurance Program Reauthorization Act, clinicians who are not eligible for an exemption must choose to participate in 1 of 2 new reimbursement models: the Merit-based Incentive Payment System or Alternative Payment Models (APMs). Although most dermatologists are expected to default into the Merit-based Incentive Payment System, some may have an interest in exploring APMs, which have associated financial incentives. However, for dermatologists interested in the APM pathway, there are currently no options other than joining a qualifying Accountable Care Organization, which make up only a small subset of Accountable Care Organizations overall. As a result, additional APMs relevant to dermatologists are needed to allow those interested in the APMs to explore this pathway. Fortunately, the Medicare Access and Children's Health Insurance Program Reauthorization Act establishes a process for new APMs to be approved and the creation of bundled payments for skin diseases may represent an opportunity to increase the number of APMs available to dermatologists. In this article, we will provide a detailed review of APMs under the Medicare Access and Children's Health Insurance Program Reauthorization Act and discuss the development and introduction of APMs as they pertain to dermatology.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: Accountable Care Organizations.

An Accountable Care Organization (ACO) is a network of providers that collaborates to manage care and is financially incentivized to realize cost savings while also optimizing standards of care. Since its introduction as part of the 2010 Patient Protection and Affordable Care Act, ACOs have grown to include 16% of Medicare beneficiaries and currently represent Medicare's largest payment initiative. Although ACOs are still in the pilot phase with multiple structural models being assessed, incentives are being introduced to encourage specialist participation, and dermatologists will have the opportunity to influence both the cost savings and quality standard aspects of these organizations. In this article, part of a health care policy series targeted to dermatologists, we review what an ACO is, its relevance to dermatologists, and essential factors to consider when joining and negotiating with an ACO.

Sunburns and risk of cutaneous melanoma: does age matter? A comprehensive meta-analysis.

PURPOSE: Sunburns are an important risk factor for melanoma and those occurring in childhood are often cited as posing the greatest risk. We conducted a meta-analysis to quantify the magnitude of association for melanoma and sunburns during childhood, adolescence, adulthood and over a lifetime. METHODS: After reviewing over 1300 article titles and evaluating 270 articles in detail, we pooled odds ratios from 51 independent study populations for "ever" sunburned and risk of cutaneous melanoma. Among these, 26 studies reported results from dose-response analyses. Dose-response analyses were examined using both fixed-effects models and Bayesian random-effects models. RESULTS: An increased risk of melanoma was seen with increasing number of sunburns for all time-periods (childhood, adolescence, adulthood, and lifetime). In an attempt to understand how risk between life-periods compares, we also report these same linear models on a scale of five sunburns per decade for each life-period. The magnitude of risk for five sunburns per decade is highest for adult and lifetime sunburns. CONCLUSIONS: Overall, these results show an increased risk of melanoma with increasing number of sunburns during all life-periods, not just childhood. Prevention efforts should focus on reducing sunburns during all life-periods.

A randomized controlled trial of high-viscosity 2-octyl cyanoacrylate tissue adhesive versus sutures in repairing facial wounds following Mohs micrographic surgery.

BACKGROUND: High-viscosity 2-octyl cyanoacrylate (HVOCA) is a rapidly polymerizing liquid topical adhesive indicated for epidermal approximation of superficial lacerations and surgical wounds. Use of HVOCA in repair of facial wounds after Mohs micrographic surgery (MMS) has not been reported. OBJECTIVE: To compare aesthetic outcome of HVOCA versus sutured epidermal closure of linearly repaired facial wounds following MMS. METHODS: Patients undergoing MMS for facial tumors with postoperative wounds >3 cm appropriate for linear closure were recruited. After placement of dermal sutures, half the wound was randomly selected for closure with HVOCA and the other half was closed with 5-0 polypropylene suture. RESULTS: Fourteen patients (13 men and 1 woman; mean age, 72+/-8.8 years; range, 52-81 years) with basal cell or squamous cell carcinoma of the face (n=12) or neck (n=2) were enrolled. The mean wound length was 4.9+/-1.9 cm (range, 3.1-10 cm). No postoperative complications, including bleeding, infection, or dehiscence, occurred. Using photographs obtained 3 months postoperatively, five dermatologists (including two Mohs surgeons) blinded to the intervention rated cosmesis using a visual analog scale from 1 (worst) to 10 (best). The mean ratings for HVOCA half (6.64+/-1.55) versus sutured half (6.77+/-1.88) were not significantly different (p=.35). Paired comparisons of rater preferences similarly showed no cosmetic differences. All 14 patients preferred OCA for ease of postoperative care. CONCLUSION: HVOCA tissue adhesive is cosmetically equivalent to epidermal sutures in the linear repair of facial wounds following MMS. This technique represents an additional option for Mohs surgeons.

Intralesional methotrexate treatment for keratoacanthoma tumors: a retrospective study and review of the literature.

BACKGROUND: Intralesional methotrexate (MTX) is an effective treatment for keratoacanthoma (KA). OBJECTIVE: We sought to systematically examine response rates and adverse events in KA treated with intralesional MTX. METHODS: All cases of KA treated with intralesional MTX at our institution from 1991 to 2006 were identified. A MEDLINE and PubMed search of cases of KA treated with intralesional MTX was also performed. RESULTS: In all, 38 cases of KA treated with intralesional MTX were identified: 18 from our institution and 20 from the literature. Intralesional MTX achieved resolution in 92%, requiring an average of 2.1 injections an average of 18 days apart. Adverse events were rare, with two reports of pancytopenia in patients with chronic renal failure. LIMITATIONS: Use of single case reports, small series, and retrospective analysis are limitations. CONCLUSION: Intralesional MTX is a useful nonsurgical therapy for the treatment of KA. Histologic diagnosis before initiation of treatment is preferred. A complete blood cell count at baseline and during treatment should be considered to monitor for potential cytopenia.

Sunscreen use and the risk for melanoma: a quantitative review.

BACKGROUND: Originally developed to protect against sunburn, sunscreen has been assumed to prevent skin cancer. However, conflicting reports include claims that sunscreen increases risk for melanoma. OBJECTIVE: To examine the strength and consistency of associations between melanoma and sunscreen use in the published literature. DATA SOURCES: A comprehensive MEDLINE search of articles published from 1966 to 2003 that reported information on sunscreen use and melanoma in humans. STUDY SELECTION: Analytic studies reporting data on sunscreen use before diagnosis of melanoma. DATA EXTRACTION: Two independent reviewers extracted data. Inconsistencies were rereviewed until agreement was achieved. When necessary, a third party resolved discrepancies. DATA SYNTHESIS: Odds ratios were pooled across studies by using standard meta-analytic techniques. Pooled odds ratios for ever use among 18 heterogeneous studies did not support an association between melanoma and sunscreen use. Variation among odds ratios was explained by studies that did not adjust for confounding effects of sun sensitivity. The lack of a dose-response effect with frequency of use (never, sometimes, or always) or years of use provided further evidence of a null association. CONCLUSIONS: No association was seen between melanoma and sunscreen use. Failure to control for confounding factors may explain previous reports of positive associations linking melanoma to sunscreen use. In addition, it may take decades to detect a protective association between melanoma and use of the newer formulations of sunscreens.